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EUROPEAN RESUSCITATION COUNCIL
European Paediatric Life Support INSTRUCTOR’S MANUAL
INSTRUCTOR’S MANUAL
Edition 4
Personal copy of Lilianna STYKA (ID: 18280)
European Paediatric Life Support
II
European Paediatric Life Support Instructor’s Manual Editors
Acknowledgements
Dominique Biarent (Chairman)
We thank Oliver Meyer for the digital preparation of the ECG rhythm strips, and Annelies Pické (ERC) for the administrative co-ordination.
Robert Bingham (Co-chairman) Souhail Alouini (Co-chairman) Gudrun Burda (ICC member) Boris Filipovic (ICC member) Patrick Van de Voorde (ICC member)
Personal copy of Lilianna STYKA (ID: 18280)
Co-authors Paolo Biban Gerard Cheron Fotini Danou Jos Draaisma Christoph Eich Christine Fonteyne Miguel Felix Mojca Groselj-Grenc Sylvia Hunyadi-Anticevic Torsten Lauritsen Francis Leclerc Anselmi Luciano Jesus Lopez-Herce Ian Maconochie Elizabeth Norris Antonio Rodriguez-Nunez Thomas Rajka Frederic Tits Nigel Turner Burkhard Wermter David Zideman
Illustrations Cover page by Griet Demesmaeker, Belgium (
[email protected]). Lay-out by Studio Grid, Belgium (www.studiogrid.be).
Published by European Resuscitation Council vzw, Drie Eikenstraat 661, 2650 Edegem, Belgium. © European Resuscitation Council 2011. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the prior written permission of the ERC. Disclaimer: No responsibility is assumed by the authors and the publisher for any injury and/or damage to persons or property as a result of products liability, negligence or otherwise, or from any use or operation of any methods, products, instructions or ideas contained in the material herein. Because of rapid advances in the medical sciences, the editor recommends that independent verification of diagnosis should be made.
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Content
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EPLS Course Programme
V
Introduction to the Course
1
Chapter 1
Basic Life Support, BLS - AED and Recovery Position
3
Chapter 2
A: Airway Opening, OPA, NPA, Suction, Bag and Mask Ventilation, CPR with BMV
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Chapter 3
A: C Spine Care and Choking
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Chapter 4
B: Breathing Skill Station: Oxygen Delivery, Intubation, ETCO2 and SpO2, Pneumothorax 9
Chapter 5
C: Circulation Skill Station: Vascular Access, Fluids and Medication
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Chapter 6
Defibrillation, Cardioversion and AED Skill Station
13
Chapter 7
Recognition and Algorithms of Cardiac Arrests & Arrythmias
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Chapter 8
Post-Cardiac Arrest Resuscitation Care
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Chapter 9
Resuscitation of the Newborn: demo and case scenarios
19
Chapter 10
Teaching Scenarios and Demos
25
Chapter 11
Respiratory Failure States - Case Scenarios
29
Chapter 12
Circulatory Failure States - Case Scenarios
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Chapter 13
Cardiac Arrest - Megacodes - Team Work - Case Scenarios
39
Chapter 14
Trauma - Case Scenarios
47
Annexes
BLS Evaluation Sheet formal evaluation
52
BLS Evaluation Sheet: continuous evaluation
52
Candidate Portfolio
54
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Glossary
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Personal copy of Lilianna STYKA (ID: 18280)
Glossary (main abbreviations used in ERC Paediatric manuals) A
Airway
IO
Intra Osseous
B
Breathing
IV
Intra Venous
C
Circulation
J
Joule
D
Disability
LMA
Laryngeal Mask Airway
E
Exposure and Environment
MET
Medical Emergency Team
AED
Automated External Defibrillator
NICU
Neonatal Intensive Care
ALS
Advanced Life Support
OPA
Oropharyngeal airway
AVPU
A= Alert, V= responsive to Verbal orders, P= responsive to Pain, U= Unresponsive
PEA
Pulseless Electrical Activity
AW
Airway
PEEP
Positive End Expiratory Pressure
BLS
Basic Life Support
PICU
Paediatric Intensive Care Unit
BMV
Bag and Mask Ventilation
PIP
Positive Inspiratory Pressure
BP
Blood Pressure
PPR
Potentially Perfusing Rhythm
SBP
Systolic Blood Pressure
PRBCs
Packed Red Blood Cells
CAT
Cardiac Arrest Team
RR
Respiratory Rate
CPR
Cardiopulmonary Resuscitation
ROSC
Return of Spontaneous Circulation
CRA
Cardiorespiratory arrest
RWTO
Respiratory rate, Work of Breathing, Tidal volume, Oxygenation
CRT
Capillary Refill Time
SpO2
Oxygen Saturation
CO
Cardiac Output
SV
Stroke Volume
CC
Chest Compression
SVT
Supra Ventricular Tachycardia
ECG
Electrocardiogram
TV
Tidal Volume
EMS
Emergency Medical System
UVC
Umbilical venous cannula
ETCO2
End Tidal CO2
VF
Ventricular Fibrillation
FBAO
Foreign Body Airway Obstruction
VT
Ventricular Tachycardia
FB
Foreign Body
FiO2 HR
Fraction of Inspired Oxygen Personal copy of Lilianna STYKA (ID: 18280) Heart Rate
ICP
Intracranial Pressure
V
European Paediatric Life Support (EPLS) Course Programme COUNTRY, CITY; MONTH DAY1ST/TH- DAY2ST/TH, 201. DAY 1, DAY, MONTH DATE ST/ TH Registration and Faculty meeting
08.30 - 09.00
Introduction of faculty, philosophy & learning goals, and practical information by the course director
09.00 - 09.45
KEY Lecture: Recognition of the seriously ill child
09.45 - 10.00
Demo of Basic Life Support
10.00 - 10.15
Coffee break
10.15 - 11.15
60 min, 4 classes
Basic Life Support
11.15 - 11.45
30 min, 4 classes (optional)
Basic Life Support (+ AED) + recovery position including BLS testing time or re-training
11.45 - 12.30
45 min, 4 classes
A - Airway opening, OPA / NPA, suction BMV and CPR with BMV (2 rescuers)
12.30 - 13.15
Lunch (+ faculty)
13.15 - 15.30
Skill stations 3 * 45 min, 4 classes
• A - Choking, C-spine care, recovery position if no second station of BLS
• B- Respiratory failure: oxygen delivery – intubation (aids); ETCO2 – pulse oximetry – tension pneumothorax
• C- Circulatory failure: umbilical / Intraosseous access; fluids and medication, massive transfusion
• Defibrillation, cardioversion (+/- AED) skill station
15.30 - 15.45
Coffee Break
15.45 - 16.30
Skill stations 1* 45 min, 4 classes
16.30 - 17.30
60 min, 4 classes
• Cardiac arrest and arrhythmia algorithms
17.30 - 18.15
Post-cardiac arrest resuscitation care (workshop- 4 classes)
• ABCDE, oxygen titration, hypothermia, glucose and seizure control
18.15 - 18.35
Mentor/mentee meeting
18.35
Faculty
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08.00 - 08.30
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DAY 2, DAY, MONTH DATE ST/ TH
08.15 - 08.45
Lecture: Resuscitation of the newly-born and ethics
08.45 - 09.45
Scenario training including demo (4 groups)
• Neonatal resuscitation
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09.45 - 10.30 Lecture: Team approach in trauma management 10.30 - 10.45
Coffee break
10.45 - 11.20
Demonstration of scenario by instructors
1. Demo circulatory or respiratory insufficiency (single hero)
2. Demo cardiac arrest (team)
11.20 - 13.20
Integrated cases – 1st session (2x60’)
• Respiratory failure (single hero)
• Circulatory failure (single hero)
• Cardiac arrest (team approach)
• Trauma (team approach)
13.20 - 14.10
Lunch + Mentors-Mentees meeting + faculty
14.10 - 16.10
Integrated cases – 2d session (2x60’)
16.10 - 16.25
Coffee Break
16.25 - 18.00
Evaluation
• 45 minutes
Written evaluation (MCQ)
• 45 minutes
Scenario testing: 15 minute each test
18.00 - 18.30
Faculty meeting
18.30
Results and feedback
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Introduction 2
Explanation by the course director at the beginning of the course
Philosophy: supportive, cross-role training, shared mental models; mentor-mentee Learning goals: skills, knowledge, teamwork and attitudes; broad basis; life saving / performance improvement Need for ongoing training –knowledge, skills and attitude- diminishes over time
As for the instructors:
Skill teaching/hands-on stations
As an instructor you give advice and, by means of the positive critiquing, correct and direct the candidate toward the predefined goals of the session. Assessment of the achievement of these goals by each of the individual candidates is an important part of the role of the instructor.
Four stage teaching method should be used whenever possible and indicated (e.g. BLS, choking, PLS, BMV, IO insertion….)
The instructor manual gives a structure for each session; the answers to the given questions are given in the EPLS course manual. Stick closely to the content of the instructor manual and the EPLS course manual. Do not overload the session with details but take sufficient time to teach the core issues and predefined goals for each session.
Questions exposed in this manual should be used only as aids during demonstrations when appropriate and not during hands-on practice because they risk to interfere and/or interrupt the flow of actions. However instructors must be ready to answer to those questions (and others). Reading of the EPLS manual must be part of the pre-course instructor’s preparation.
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Introduction to faculty & practical information (e.g; time keeping)
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1
CHAPTER
Basic Life Support, BLS - AED and Recovery Position
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2
Goals Each participant must be able to perform a full sequence of paediatric basic life support. Specific attention should be given to the skills of airway opening and ventilation, as well as to the rate and depth of compressions. Hands-off time should be minimal. At the end, participants are shown how to position a spontaneously breathing victim in a recovery position and how to restart BLS when indicated.
◆ 2 BLS Manikins (one infant and one junior) ◆ Max. 3 candidates for one instructor ◆ Face shield (optional) ◆ Cleaning ◆ Teaching purpose AED (optional)
Outline Total = 15 min (demo) + 60 minutes + 30 minutes (optional) ◆ Global approach includes 4 stage teaching
• Stage 1: silent demonstration by instructor • S tage 2: instructor demonstrates and comments his own actions • S tage 3: candidate indicates actions and instructor demonstrates • Stage 4: candidate performs actions
Basic Life Support First Part: all candidates: gathered for BLS demonstration: 15 minutes. A BLS demonstration (stage 1 to 2; infant or small child,) is performed by 2 instructors. Head tilt-chin lift will be the only airway opening manoeuvre taught in this station (universal manoeuvre) After stage 2 time for candidates is given. Second Part: 4 parallel groups: 60 + 30 minutes. One candidate performs stage 3 guiding the instructor and
then stage 4 for the infant/small child. Both the instructor and the other candidates observe. The positive critique method is time consuming but some comments can be given during the candidate’s performance provided the candidate is allowed to progress into the sequence. (e.g. if the candidate is unable to open the airway and to demonstrate visible chest movement: the instructor may help the candidate to correct head position allowing him to continue progressing into the sequence.) After the candidate has completed the sequence some additional critiques (in a positive method) can be added. BLS sequence (4 stages) is repeated for older children and differences are explained. Use of face shield or mouth to mask may be added.
Questions that instructors must be able to answer ◆ What
is most frequent cause of cardiac arrest in children? ◆ Which sequence of activation of EMS should you use by age and type of victim? ◆ How should you deliver rescue breath (quantity and quality)? ◆ What are the causes and what should you do if the chest does not rise? ◆ What is meant by ‘signs of life’ and why is this important? What is meant by ‘gasping’? ◆ How should you deliver chest compressions (quantity and quality)?
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Equipment
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Chapter 1 Basic Life Support, BLS - AED and Recovery Position
Recovery position Indications for the recovery position in a spontaneously breathing child are briefly discussed. The ‘recovery position’ is demonstrated and candidates perform it by groups of 2, including when and how to restart BLS when indicated.
BLS + AED (optional)
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Goals Each participant must be able to perform a full sequence of paediatric basic life support, including the use of an AED. Again proper attention should be given to the skills of BLS (airway opening and ventilation, rate and depth of compressions). Importantly, hands-off time should be minimal. The candidate should know the indications and the safe and correct use of the AED. The assessment of the achievement of these goals by each of the individual candidates is an important part of the role of the instructor.
Outline Total = 30 minutes 4 groups. If necessary (i.e. two AED available) the teaching period for AED can vary during the 90 min of the BLS skill station. A BLS demonstration (4 stage infant or small child, 2’ each stage) is performed by 2 instructors. AED is introduced as in the guidelines after 1’ CPR by a second person. In the demonstration the rhythm is a non-shockable rhythm. CPR is recommenced immediately before the demonstrations stops. ◆ Specific
explanation is given about how the proper use and attachment of an AED. ◆ For two candidates the sequence is repeated for the small child with AED attachment after 1’ CPR. The
second candidate brings in the AED and explains his/ her actions to the first candidate as they are happening ◆ BLS sequence is repeated with older child (shockable rhythms). Time is given for a Q&A (see below) by candidates and/or instructor.
Q&A When should an AED be applied in children? How is the AED integrated in the BLS algorithm? With one rescuer – with two rescuers? Can an AED be used in children <1y? Can an AED be used without a paediatric attenuator in children <8 y? What safety measures should be taken when using an AED?
Closure Candidates should be given a formal opportunity to ask any questions. When these have been answered to the candidates’ satisfaction, the session can be closed by repeating the procedures used.
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CHAPTER
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A: Airway Opening, OPA, NPA, Suction, Bag and Mask Ventilation, CPR with BMV
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Goals
Equipment
Bag and mask ventilation
◆1
BLS Manikins (infant); + 1 ALS junior (to accommodate a oropharyngeal airway) or one ALS manikin and one BLS junior ◆M ax. 3 candidates for one instructor ◆C leaning material ◆D ifferent types of bags (self-inflating and free-flow) of different sizes and masks of different shapes and sizes ◆O PA (various sizes) and NPA (or shorten tracheal tubes with safety pins) ◆S uction equipment
The workshop should be started by discussing how to handle a small child with decompensated respiratory failure (and hence decreased consciousness)
Outline
◆ What is important in the choice of mask? ◆ What is the role of the pressure-limiting valve? ◆ What are the risks of hyperventilation? ◆ How to allow for spontaneous ventilation? ◆ How can you evaluate effectiveness of ventilation? ◆ What are potential reasons for ventilation to be inef-
Total = 45 minutes One of the four parallel sessions, groups will change to another classroom after 45 minutes
AIRWAY OPENING, OPA, NPA Discuss and demonstrate head positioning for airway opening according to age (universal manoeuvre and jaw thrust with head tilt). Discuss indication and sizing and demonstrate insertion of airway opening devices: oro- or naso-pharyngeal airways. ◆ How should airway be opened in a trauma patient? ◆ How to check that airway is open? ◆ What should you do if the mouth is full of milk?
Useful questions instructors can use to start the workshop or that they should be able to answer ◆ Which types of bags exist? What are their (dis) advantages? ◆ Which bag would you choose for which child (includ-
ing correct volume of bag)?
fective? Think ALPES • A irway positioning • L eak mask • P neumothorax • E quipment • S tomach
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The candidate must know how to open the airway effectively in infants and in children; he/she must know the indications and techniques of oropharyngeal and nasopharyngeal airway insertion and of suctioning. He/she must know the advantages and disadvantages of the different types of available bagmask systems, be able to choose the correct size of bag and mask and properly apply the mask to the face. The candidate must then be able to adequately ventilate a patient by means of BMV, both 1 and 2 persons, both on its own and in association with ongoing BLS CPR.
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Chapter 2 A: Airway Opening, OPA, NPA, Suction, Bag and Mask Ventilation, CPR with BMV
Demonstration by the instructor Bag and mask ventilation should be demonstrated by the 4 stage approach (see chapter 1 BLS) Attention is given to ABCDE approach with adequate airway opening. The need to assist ventilation is recognised and BMV is started (if not available: start without!). The correct positioning of the hands (one hand to open the airway and seal the mask on the face: “E clamp; C clamp”, one hand to squeeze the bag) is explained. The correct technique of sizing and placement of oropharyngeal and nasopharyngeal airway is demonstrated by the instructors
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Hands on ◆ All candidates perform BMV on both a baby and a larg-
er child, under supervision of an instructor. Candidates comment on the effectiveness of their ventilation. ◆ Per two candidates BMV is performed in a larger child with sick and stiff lungs; there is need for two-person technique and initially overriding the pressure-limiting valve might be necessary. ◆ Each candidate practises sizing and placement of an oro- and nasopharyngeal airway ◆ Per two candidates BMV is performed as part of BLS CPR in an infant or small child
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A: C Spine Care and Choking
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CHAPTER
Goals
The candidate must further know how to evaluate airway opening and when to suspect foreign body airway obstruction. He/she must know the correct actions for both a conscious and unconscious patient.
Equipment ◆M anikins:
BLS baby (FBAO if available), junior (ALS if available or BLS with arms and legs) ◆o ro- and nasopharyngeal airways ◆B ag and masks ◆g loves – cleaning material ◆c ervical collars of different sizes ◆h ead blocks – tapes ◆S pine board (optional)
Outline Total = 45 minutes One of the four parallel sessions, groups will change to another classroom after 45 minutes. The station starts with a brief introduction about the goals of this skill station. Afterwards, if the classroom disposition allows it, the group can be divided in 2. One group will work on C-Spine and the other on choking and then both groups swap.
C-Spine management 20’ One instructor will go into details about airway management in trauma.
Airway opening is demonstrated once again by an instructor in conjunction with BMV.
Questions that the instructors must be able to answer ◆ Why
is the airway often at risk in paediatric trauma and why is airway management in trauma sometimes difficult? ◆W hy is it important to protect the cervical spine and how can this be done? ◆W hat do we do if a trauma patient vomits? The choice of, the measurement and placement of a cervical collar on a candidate or manikin (sitting and lying) is demonstrated and discussed. Further fixation of the neck and the rest of the body ‘in-line’ with each other is demonstrated and discussed. The (dis)advantages of a spine board or a vacuum mattress are briefly discussed.
Hands on Each candidate should have time to train the correct measurement and placement of a cervical collar. This can be done on another candidate so that he can comment on any neck mobilisation during collar placement. Log roll should be performed with 3-4 candidates under the supervision and with the guidance of the instructor.
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The candidate already knows how to open the airway effectively in infants and in children; he/she knows the indications and techniques of OPA and NPA and of suctioning (normally this is already explained in the Airway session- see chapter 2). This session specifically focuses on correct airway management in case of trauma. The candidate should be able to place a cervical collar correctly, avoiding mobilisation of the child. He/she must know why it is important and how to maintain the cervical spine in-line, avoiding rotation of the body in relation to the spine. He must know how to perform a log-roll.
Chapter 3 A: C Spine Care and Choking
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Choking
20 min
Another instructor will focus on choking
Demo The instructor demonstrates choking manoeuvre in infant and children.
Questions ◆W hat are signs of / how to recognise presumed foreign
body aspiration?
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◆ 2 core Q need to be asked in case of presumed choking:
• Is coughing still effective (what is meant by ‘effective’)? • Is the patient still conscious?
From these 2 questions it is possible to derive the algorithms • E ffective cough • Ineffective coughing in conscious infant • Ineffective coughing in conscious child •U nconscious infant/child
Hands on Each candidate should practise back blows, chest thrusts and/or Heimlich manoeuvre. Additional Q: How long to continue the manoeuvres? When to try and extract a foreign body from the airway? When to call for help?
Closure
2-3 min
Close the session with formal opportunity to ask any questions. Repeat the core Q associated with choking management and emphasize the importance of airway management and C-spine in line immobilisation.
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CHAPTER
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B: Breathing Skill Station: Oxygen Delivery, Intubation, ETCO2 and SpO2, Pneumothorax
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Goals
The indications and basic interpretation of capnography are considered necessary knowledge. The candidate knows what problems may arise in ventilated children (DOPES) and what can be done to treat these (e.g. gastric tube, pneumothorax drainage). Difficult airway management and intubation aids are briefly discussed and/or demonstrated.
Equipment ◆m anikins
ALS baby - junior or intubation heads (to accommodate ETT etc.) ◆B ag and mask ◆g loves – cleaning material ◆D ifferent types of oxygen devices: head box, nasal prongs, non-rebreathing masks with valves… ◆D ifferent sizes and types of TT tubes, laryngoscope, blades, tape, stylet ◆S uction material ◆L arge bore catheter + syringe for decompression of tension pneumothorax ◆ I ntubation aids: LMA, gum elastic bougie ◆B oard or flipchart
Outline Total = 45 minutes
One of the four parallel sessions, groups will change to another classroom after 45 minutes First part 25 min ◆ The instructor repeats the signs of respiratory failure (RWTO) and briefly discusses what happens when decompensation occurs. ◆ Q1: Which actions should be undertaken for children with
compensated and decompensated respiratory failure? The difference between oxygenation and ventilation is explained. • Different devices for oxygen delivery are demonstrated: nasal prongs, oxygen mask, high concentration mask. For each the necessary flow, device specifics and FiO2 are taught. • The indications for oxygen and the risks associated with hyperoxia are explained. Pulse oximetry is a way of titrating FiO2 after initial stabilisation. Its use is further explained.
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The candidate must know how to recognize respiratory failure and signs of decompensation. He must know the difference between oxygenation and ventilation and how to support both. He/she must know the different ways of administering oxygen (devices). The candidate will need to know the indications and (dis)advantages of intubation and the material needed for it (including appropriate sizes). Rapid Sequence intubation RSI is briefly discussed and the opportunity is given to try intubation on a manikin (not mandatory). Importantly, it is underlined that proper training in intubation demands repeated training in e.g. operating theatre under the supervision of an experienced and skilled person and is not a goal in this course. Instead the importance of BMV is emphasized.
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Chapter 4 B: Breathing Skill Station: Oxygen Delivery, Intubation, ETCO2 and SpO2, Pneumothorax
◆Q 2: Which patients should be intubated? What are the
(dis)advantages of intubation? • T he sequence of RSI is discussed with the group, as well as the necessary material (incl. proper sizing of TT – blade – intubation depth). •A re there situation where RSI (i.e. the use of medications) is not necessary? What are possible adverse effects of not using medication? • What can you do if a difficult intubation is anticipated? • Intubations aids like LMA and gum elastic bougie may be demonstrated by an instructor • How can you verify that intubation is adequate?
◆T he
importance of ETCO2 measurement and the interpretation of capnography are discussed
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◆Q 3:
What problems may arise in ventilated children (DOPES) and what can be done to treat these: gastric tube, decompression of pneumothorax...? •W hat are the risks of hyperventilation?
Second part 20 min ◆T he instructor demonstrates the emergency decompression of a tension pneumothorax. ◆T he candidates are given time to practice intubation on a manikin. However, the importance of BMV is emphasised once more. Manikin intubation is NOT sufficient to safely perform intubations in real life situations!! ◆ I f there is time available candidates may practice the use of LMA and/or gum elastic bougie.
Closure Candidates are given the opportunity to ask final questions. Summarise the core informations concerning oxygenation and ventilation.
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CHAPTER
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C: Circulation Skill Station: Vascular Access, Fluids and Medication Goals The candidate must know how to recognise circulatory failure and signs of decompensation. He must know how to initiate the treatment. (Dis) advantages of all vascular accesses are discussed. The algorithm for placement of a vascular access in cardiac arrest and decompensated shock are discussed.
Equipment ◆M anikins ALS baby -
junior that accommodate IO needle or chicken or turkey legs may be used as an alternative, artificial bones for EZ-IO devices ◆ I O needles, EZ-IO device ◆P eripheral catheters, syringes, fluids ◆U mbilical cords (synthetic, animal or human models, according to local policies) ◆ Feeding bottles + teats (x nr of candidates in each group; the cords will be inserted tightly through a feeding bottle teat (prepared by instructors); bottle filled with dyed saline) ◆U mbilical catheters; tapes or ribbon (to secure the cord), scalpel (x nº of candidates in each group) ◆G loves / aprons– cleaning material ◆B oard or flipchart ◆N ote that inform consent for use of umbilical cords are required in some countries.
Outline Total = 45 minutes One of the four parallel sessions, groups will change to another classroom after 45 minutes First part 15 min ◆T he instructor repeats the signs circulatory failure and briefly discusses what happens when decompensation occurs.
Which actions should be undertaken initially for children with circulatory failure or for children in cardiac arrest? • The different ways of vascular access and their (dis) advantages are discussed (see also part 2). The indications for femoral vein access are discussed, but the skill is not taught in part 2. Vascular access should never interrupt CPR. • The different types of fluids and their (dis)advantages are discussed. • How much fluid should be given and how should you evaluate this?
◆ Q1:
◆Q 2: What are the indications to start vasoactive medica-
tion? The dose, activity and side-effects are discussed briefly (for more details refer to the EPLS manual) for adrenaline, noradrenaline, dopamine and dobutamine, as well as for Glucose, Bicarbonate and Calcium. Demonstration of Broselow tape.
Hands on: 30’ The group is further split into two so that max. 3 candidates per instructor. 2* 15’. ◆O ne
instructor demonstrates umbilical vein insertion technique. Afterwards each candidate gets time to practice the technique. • Loosely tie the umbilical tape around the cord • Cut the cord with a scalpel, leaving a 1 cm strip distal to the tape • Identify the umbilical vein. 3 vessels will be seen
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Each candidate should achieve practical skill both in intraosseous infusion placement, and in umbilical catheterisation. The indications and complications of each of the manoeuvres should be addressed. The indications and technique of femoral vein access may be discussed briefly but is not a skill that is taught in this station.
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Chapter 5 C: Circulation Skill Station: Vascular Access, Fluids and Medication
on the stump. Two will be small and contracted (the arteries) and one will be dilated (the vein). • F ill a umbilical catheter with N saline • Insert the catheter into the vein and advance it about 5 cm. • T ighten the umbilical tape to secure the catheter. A string suture may be used to further secure the catheter in place. instructor demonstrates intraosseous needle insertion both using simple IO needle and EZ-IO device. Landmarks for tibial, femoral and humeral insertion and criterias of correct positioning of the intraosseous needle are discussed. Afterwards each candidate gets time to practice both techniques.
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◆O ne
Closure Close the session with formal opportunity to ask any questions. Repeat the algorithm of placement of vascular access in circulatory failure and CPR.
6
CHAPTER
Defibrillation, Cardioversion and AED Skill Station
13
Goals / Assesment
Equipment
◆ The instructor demonstrates the use of an AED
◆ Manikins ALS baby - junior (to accommodate defibrillation) ◆B ag and mask ◆g loves – cleaning material ◆M onitor-defibrillator with printer ◆A rrhythmia simulator: Heartsim or Dräger ◆T eaching purpose AED (optional) ◆G el pads, self-adhesive electrodes
A demonstration is given of a ‘shockable’ arrest sequence: 1 defib. with paddles and/or 1 with self-adhesive pads (stage 1 and 2 demo)
Outline
If sufficient amount of material is available (i.e. 2 defibrillators and two defibrillable manikins), the candidates may be split into two groups (3 candidates per instructor). Each instructor will try to exercise 2 scenarios with the candidates. In each scenario there is one team leader who takes care of AB and directs the other candidates in their actions during CPR; one candidate performs chest compressions; a third candidate uses the defibrillator. After 2’ the person doing chest compressions is replaced and will be the next to perform defibrillation. It is important that each team member has the opportunity to use the defibrillator at least once with each instructor. The focus in this skill station is on the skill (defibrillation) and the integration of this into the ALS algorithm, not on scenario training as such.
Total = 45 minutes One of the four parallel sessions, groups will change to another classroom after 45 minutes First Part 15-20 min ◆T he instructor explains the controls and usage of the device. Attention is given to: •M onitoring rhythm (incl. artefacts); correlating rhythm with signs of circulation •P addles – pads – self-adhesive pads; including size and position • Energy level/charging •D efibrillation vs. Cardioversion (incl. place of cardioversion in tachy-arrhythmias) ◆T he instructor then discusses the place of defibrillation
in the ‘shockable’ arrest: • T iming •C horegraphy with emphasis on safety, action planing and ‘hands-off’ time
Second Part 25-30 min Candidates practice safe defibrillation as stage 3 and 4. When all candidates have demonstrate ability to safe defibrillation, scenarios can be proposed.
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Each participant should know the algorithms of cardiac arrest and arrhythmias and the proper place of a defibrillator in these algorithms. He/she should know how to use a defibrillator properly and the difference between cardioversion and defibrillation. This concerns both the usage of the device and sequencing of defibrillation within the algorithm of ‘shockable’ cardiac arrest. The use of defib paddles and self-adhesive pads should be discussed. Attention should be given both to provider safety and minimal hands-off time. AED use is discussed if not covered earlier.
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Chapter 6 Defibrillation, Cardioversion and AED Skill Station
Case 1 5 year old boy,is found in a pond outside in winter (cold). Rhythm = VF. CPR is commenced with a team of 3 and defibrillator is attached by means of self-adhesive pads. A first shock is given and 2’ CPR performed. A second shock is given and 2’ CPR performed. Rhythm then changes at 6’ to PEA and story will continue in hospital (cf drowning and hypothermia)
Case 2
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In a shopping mall, you are walking. Suddenly, in front of you, a 2 year old child collapses. There is an AED in front of you and somebody calls EMS for you. You start BLS and ask the other person to bring back the AED after having summon EMS. After one minute, you place the electrodes and follow the instructions. One shock is given and during the next period of CPR the child shows signs of life.
Case 3 A 1 year old girl. Unwell since this morning, only responding to pain, breathing fast (and shallow). CRT 6”, weak peripheral pulses, systolic BP 50. HR 280/’. Rhythm SVT 1 dose of Adenosine if line in place, but this is not the case in this child cardioversion 0.5-1 J/kg synchronised; second attempt 2J/kg after which sinus.
Case 4 A 2-year-old girl, operated for cardiac surgery 2 months ago, suddenly collapses in front of you. CPR is commenced with a team of 2. A manual defibrillator is brought in by a third person. No self-adhesive pads; a ‘quick look’ can be performed but ECG electrodes are preferred. The rhythm is VF. 3 shocks with paddles are needed and one round of medications before rhythm changes at 8’ to sinus with ROSC.
Case 5 CASE 2: 5-year-old boy. Unwell since a few days, today pale, asthenic and eventually unconscious. Intubation is performed and then rhythm on the scope rapidly changes from tachycardia to bradycardia and asystole. After 2 min CPR + 1 dose Adrenaline: a rhythm control shows VT- there are no signs of life. A defibrillator is attached by
means of self-adhesive pads. A first shock is given and 2’ CPR performed. A second shock is given and 2’ CPR performed. Rhythm then changes at 6’ to sinus with ROSC.
Closure Candidates are given the opportunity to ask final questions. A brief summary is given. Finally we emphasise once more the importance of minimal hands-off time (keeping safety in mind).
7
CHAPTER
15
Recognition and Algorithms of Cardiac Arrests & Arrythmias
2
Goals Each candidate must be able to perform rapid diagnosis of the fundamental rhythms in paediatric cardiac arrest (signs of life?). He/She must be able to recognize the most common rhythm disorders in relation to signs of shock. At the end of the workshop, the candidate should know the different algorithms of management in cardiac arrest and non-arrest arrhythmias.
◆E CG
Strips + overhead projector or LCD projector and laptop ◆o r Rhythm simulator and monitor ◆F lipchart or board
Outline Total = 60 minutes; 4 groups The whole session is build up around core questions that the candidates need to ask themselves when confronted with a child with arrhythmia/ cardiac arrest rhythms. The instructor tries to find these questions together with the candidates and then gradually builds the algorithms on the board/flip chart. ECG strips or simulator/monitor should be used. To be able to interpret abnormal values, the candidates should have an idea about normal values of parameters for age (HR, BP, QRS). First start with an ASSESSMENT SSS (consciousness) – A–B-C ◆Q 1: Are there any signs of life? (or definite pulse >60’) •W hat are signs of life? • T reat the patient, not the monitor! ◆Q 2: if NO signs of life, start CPR and analyse rhythm
• I s this rhythm shockable or non shockable? The instructor shows examples of shockable and non-shockable rhythms and ensures that all candidates are able to recognise them: asystole, bradycardia without signs of life, PEA, VT without signs of life, VF (coarse and fine)
◆ Q3:
if the rhythm is non shockable, continue CPR and minimise interruptions • Give adrenaline every 3-5 min if the rhythm is shockable: continue CPR and minimise interruptions • What is most important in case of shockable rhythms? • How is defibrillation integrated in this algorithm? When should the rhythm be re-evaluated?
◆ Q4:
◆ Q5:
Which actions can be done during CPR? When should the rhythm be re-evaluated? • What is the advantage of intubation – what are the risks? For what is capnography used? • What are reversible causes of cardiac arrest and what is their importance? • How to optimise the quality of CPR?
Display the full algorithm as in the EPLS manual if there are signs of life, and after AB evaluation and treatment, evaluate circulation • Are there any signs of shock – is this shock already decompensated? • Is the heart rate fast or slow? • Are the QRS complexes narrow or wide? (regular or not?) The instructor shows examples of brady- and tachyarrhythmia and assures that all candidates are able to recognise them: sinus bradycardia, AV block, sinus tachycardia, SVT, VT with perfusion. The term ‘Potentially Perfusing Rhythms’ is explained.
◆ Q6:
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Equipment
16
Chapter 7 Recognition and Algorithms of Cardiac Arrests & Arrythmias
if bradycardia, what are the potential causes? How can you differentiate between them? What is the preferred management?
◆Q 7:
If narrow complex tachycardia, what are the potential causes? How can you differentiate between them? •W hat is the indication for vagal manoeuvres? For chemical and for electrical cardioversion? •A re there specific things to consider with chemical cardioversion? •A re there specific things to consider with electrical cardioversion?
◆ Q8:
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◆Q 9: If broad complex tachycardia, what are the poten-
tial causes? How can you differentiate between them? •W hat is the indication for medications? For electrical cardioversion? •A re there specific things to consider with electrical cardioversion?
Closure Close the session with formal opportunity to ask any questions. Finally repeat the core questions around which this session was build and their relation to the given algorithms.
8
CHAPTER
Post-Cardiac Arrest Resuscitation Care
17
2
Goals To familiarise the candidates with all aspects of the post-resuscitation period and prevent recurrence of arrest or instability. Specific attention is given to adequate titration of oxygen therapy, normoventilation, haemodynamic support, brain protective measures including glucose control, seizure control, temperature control etc.
◆F lipchart or board ◆O ther option: intubated manikin with IV or IO access.
Outline Total = 30-45 minutes; 4 groups The whole session is build up around case 1 or 5 of defibrillation skill station (the one that has been done in the skillstation). Using an ABCDE approach, all necessary measures that need to be taken early after ROSC will be discussed. The emphasis should be on brain protection “cerebral resuscitation’. The underlying idea is that only part of the damage is done and brain tissue can be saved if secondary damage can be avoided! Start from where the case was stopped; you are about to contact the accepting team (intensive care unit in your own or a referral hospital). AB Stabilization of Airway and Breathing • Intubation (if not yet; confirmation of correct tube positioning) •R EMEMBER DOPES and how to prevent/treat it: fixation, suctioning, gastric tube... • Ventilator settings: see manual, AVOID hyperventilation •M onitor ETCO2 (in view of the above) • T itrate oxygen to SpO2 94-98% C Stabilization of Circulation • S ecure and sufficient vascular access •M onitoring (HR & 4P): ECG, SpO2, ETCO2, urinary output •A VOID hypotension: Fluids as needed (circulating volume); Inotropic and/or vasopressor support (see manual and skill station)
D Neurological stabilization (see EPLS manual trauma chapter) • ABC (see above)- Monitoring (see above; GCS; pupil) • Normoglycemia (glucose or insulin (with care) as needed) • AVOID hyperthermia: treat aggressively with antipyretics or by physical means • Hypothermia: if the child is hypothermic after resuscitation rewarm him up to 32°C and then don’t try to rewarm it further • Initiate deliberate hypothermia (32-34°) • Venous drainage – head position • Analgesia (muscle relaxants?) • Seizure control E - and also.. • Contact / support relatives • Patient’s history: what has happened, previous illnesses, allergies, medications (AMPLE) • Make a start to diagnostic work-out: x-ray, biochemistry, blood gas analysis, urinalysis... • Considere certain additional treatments in view of the story: antibiotics, steroids, surgical input, antidotes, dialysis etc. Preparation for transport • Communication with accepting team • Vehicle – staff – equipment • ABCD check: sufficient oxygen, secure tubes and lines, ventilator settings, monitoring, • temperature
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Equipment
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18
Chapter 8 Post-Cardiac Arrest Resuscitation Care
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CHAPTER
19
Resuscitation of the Newborn: demo and case scenarios
2
Goals At the beginning of the session, the instructors will do a demo of a full resuscitation (like in scenario X). The instructors will emphasise preparation, protection of the child from cold and draught (the baby must be adequately covered including the head with warm and dry towels), stimulation and adequate bag and mask ventilation. After the demo, case scenarios are made by one candidate with the help of a second one. Each candidate should do one scenario. (if needed split up the groups further; 1 instructor per 3 candidates provided enough material and manikins are available).
◆O ne manikin (preferably ALS baby or newborn but BLS
baby may be used)
◆5 00 ml –bag, (T-piece), Masks 0, 1 ◆L aryngoscope + blades 0-1 Miller ◆S uction catheter ◆U mbilical catheter + 3-way stopcock ◆S yringes, glucose, adrenaline & NaCl 0.9 % ampulla ◆3 -4 towels ◆S tethoscope
OUTLINE Demo 10 min: full CPR Scenarios 50 min
Scenario 1 Hypotonic newborn You are called to the ED for a delivery from a 15-year-old girl. After birth, the baby, a boy, is hypotonic and cyanotic.
Information for the instructor (to answer to candidate’s evaluation of the newborn) ◆N ot meconium stained ◆S ingle full term child ◆T he baby does not cry and is breathing irregularly ◆H R 100/min ◆T one is very poor ◆C yanotic
Development When covered with a warm towel, dried and stimulated, the child starts to cry, his HR rises (HR 130/min). If a oximeter is placed by the candidate: SpO2 is 40% but when the breathing becomes more adequate the SpO2 increases to 70% at 2 min and 85 % at 4 min. However in this simple case, the placement of an oximeter is not mandatory If these simple measures are not realised (or too slowly) the heart rate decreases at 80/min, the baby shows only gasps and SpO2 remains too low. It becomes necessary to open the airway and give 5 inflation breaths with BMV and room air. if done adequately: chest moves, heart rate rises from 80 to 130/’; SpO2 gradually increases and child starts breathing more regularly if not: the heart rate remains low and the child only shows gasping, until adequate BMV is given.
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Equipment
20
Chapter 9 Resuscitation of the Newborn: demo and case scenarios
Intervention Prepare appropriate environment and equipment, start the clock A Position the baby Dry, place on dry linen and cover the head Open airway B Check breathing and HR C Assess heart rate Reassess ABC After reassessing the baby, give him to the mother.
Scenario 2 Hypotonic newborn A 30-year old multigravida has arrived in the Accident and Emergency Department with impending delivery (crowning on quick examination). There is no on-site obstetric department. The mother is in good health and has had antenatal care.
Informations for the instructor ◆N o meconium ◆S ingle full term child ◆N o cry, no breathing ◆B radycardic (<100/min) ◆T one absent (no history of maternal narcotic usage) ◆P ale and dusky
Unacceptable actions ◆C orrect sequence is not followed: “resuscitation” of the NB
must start with covering, drying and non invasive stimulation.
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Key points ◆T he vast majority of the newborns require only stimulation
(i.e. drying) to start breathing adequately;
◆T he first and almost unique problem encountered in deliv-
ery room is asphyxia which requires bag and mask ventilation with room air. Review the evolution of SpO2 after birth.
Development After drying and wrapping in towels the baby remains hpotonic and apneic. HR is below 100/min. Bag and mask ventilation is started, head positioning and pressure and inspiratory time must be modified until a good chest rise is obtained before moving to C. When appropriate BMV is delivered the HR increases above 100/min (SpO2 70 % a 3 min and 80 % at 5 min). At 5 min she has good muscle tone, cries lustily and heart rate is 140. No further interventions are indicated
Intervention A B C
Position the baby Place on dry linen and cover head Dry, Stimulate Assess breathing and HR Place pulse oximeter Start BMV with room air (30 seconds) Assess B (adequacy of chest rise) and modify BMV (pressure and Ti until chest rises). Place SpO2 Assess heart rate Re-assess ABC
Unacceptable actions ◆A ppropriate sequence not followed ◆G iving oxygen despite acceptable SpO2
Key point ◆R esuscitation-orientated history ◆P reparation (advance and immediate)
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Scenario 3 Bradycardic newborn – Full Cpr You are called to assist at a delivery of a term baby in the Accident and Emergency Department. There is no on-site obstetric department. The baby is delivered with a knot in the umbilical cord and is handed to you as you arrive.
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Key point ◆S tructured ABC approach: place of chest compressions in
the algorithm, place and dose of adrenaline
◆C PR ratios ◆ Intubation may assist management but is not essential dur-
ing resuscitation
◆P otential outcome may be poor despite initial response
from CPR
Informations for the instructor
◆D iscuss ethics (when to stop) and post cardiac arrest manage-
ment in asphyxic newborn e.g. how to manage temperature
◆N o meconium ◆S ingle full term new-born ◆D oes not cry – apnoeic ◆H R undectable ◆C ompletely floppy ◆W hite
Inflation breaths by BVM with room air result in good bilateral chest expansion but SpO2 remains undectectable (as HR) and FiO2 must be stepwise increased to 100%. The heart rate remains undetectable until after chest compressions (CC), umbilical venous cannula (UVC) inserted and medications delivered. After 1 dose of adrenaline, a slow heart rate is detected and the baby eventually gasps. With continuous BMV heart rate goes up to 120/’ eventually. The first SpO2 measured is 65% at 4’ but this rises gradually and FiO2 should be weaned in view of SpO2. The case will not evolve if there is no good BMV with chest expansion.
Intervention A Position the baby Place on warm and dry towels and wrap the head and body B Check breathing and HR Assess airway and ensure patency (suction if necessary) Deliver inflation breaths with BMV and room air Assess breathing (adequacy of chest rise) C Assess HR Install SpO2 Increase FiO2 up to 100% according to SpO2 Commence CC (30 seconds) Assess HR Establish vascular access via UVC Administer adrenaline Continue CPR and consider further medication as indicated
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Development
9
22
Chapter 9 Resuscitation of the Newborn: demo and case scenarios
Scenario 4 Hypovolaemic newborn
Scenario 5 Meconium aspiration
You are called in the delivery room for a C section for bad foetal monitoring and placenta abruptio.
You are called in the delivery for a thick meconial fluid. When arriving, the baby is born.
Informations for the instructor
Informations for the instructor
◆T he amniotic fluid is clear ◆H e is slightly premature (35 weeks) ◆A t birth, the child does not cry, or breathe ◆T he tone is absent ◆C olour is pale and cyanotic
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Development The baby must be dried and stimulated. After opening the airway, rapid suctioning and 5 inflation breaths with BMV and room air, HR is still absent. Pulse oximeter is placed. After 30” of BMV without improvement oxygen can be added up to 100% in view of SpO2 (preductal). CC are started, an umbilical catheter is placed and a first dose of adrenaline given. There is no improvement and the baby remains very pale. A bolus of fluid (blood is available) is administered. The HR is then 30 per min and the baby starts gasping. After the second dose adrenaline the rhythm is 80 and CC may be stopped. Stabilisation after resuscitation must be emphasised
Intervention A Place the baby on warm towels, wrap head and body Rapidly suction the oropharynx Assess airway patency B Assess breathing and HR BMV with room air (30 seconds) Assess B (adequacy of chest rise) Place SpO2 Add oxygen according to SpO2 C Assess HR with the stethoscope Start CC Umbilical catheterisation Adrenaline IV Intubation Fluid expansion 10 ml/kg crystalloid or PRBC’s Reassess chest rise and HR Give a 2nd bolus if adrenaline Reassess Heart rate Continue post-resuscitation care Key point ◆S tart rapidly the sequence of resuscitation ◆E mphasize fluid expansion ◆D iscuss vascular access ◆P lace of tracheal administration of adrenaline
◆M econial stained baby ◆F ull term ◆D oes not cry, does not breath adequately ◆H R 80 ◆H ypotonic ◆C yanotic
Development After suctioning of thick meconium from the trachea (once or twice according to HR), heart rate is below 60. Inflation breaths (by tracheal tube or BMV depending on candidate experience) results in some bilateral chest expansion The heart rate remains very slow under 60 and there is no spontaneous breathing Effective ventilation must be achieved and chest compressions initiated Following 1 minute of effective CPR, the HR slowly rises and the baby starts to gasp.
Intervention A Position the baby Do not stimulate Aspirate the oropharynx (head on the side) B Assess breathing and HR Monitor SpO2 Direct laryngoscopy and intubation Direct suction of the tracheal tube Remove the tube while suctioning (direct aspiration with large-bore tube) Assess HR Start to ventilate (on tube or with bag and mask) Assess breathing (adequate chest rise) Increase FiO2 for a correct SpO2 according to the time after birth C Assess Pulse Start CC (30 cc) Assess pulse Start CC Reassess after 30 sec Stop ECC when HR > 60 Stabilise Transfer in NICU
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23
Unacceptable action Dry and stimulate the baby Key point Stress the difference in 2 situations I. The newborn is cyanotic, hypotonic, non breathing ◆D o not stimulate ◆A spirate quickly the pharynx ◆ Intubation without BVM and aspirate the trachea directly on the TT removing slowly the tube ◆R eintubate the baby a 2nd time or initiate BMV ◆A spirate and remove the tube only if HR>60/min ◆U ntil the aspiration is clear ◆V entilate and do CC if the baby becomes bradycardic
II. The newborn is pink, tonic, breathing: he should be managed as all newborns In this case, intubation or even direct laryngoscopy can do harm more than be benefical.
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Risks of meconial aspiration ◆ Pneumothorax ◆ Pulmonary arterial hypertension ◆ Meconial pneumonia
9
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24
Chapter 9 Resuscitation of the Newborn: demo and case scenarios
10
25
Teaching Scenarios and Demos
CHAPTER
Before starting the scenario (“waiting the child’s arrival in the ER”), The candidate has the opportunity to write down some calculations of drugs, weight… (this helps the candidate to prepare him/herself for the scenario); however, don’t ask all calculation to every candidate (to diminish time loss).
All scenarios are built on the rapid ABCDE assessment of the manual. The candidate receives a short clinical scenario and a first glimpse of the child. He should ask questions or ask for monitoring to obtain additional information or values of parameters (e.g. BP, HR, SpO2 etc). Safe approach in-hospital means airway barriers, gown, gloves, masks if required. In respiratory and circulatory failure scenarios (chapters 9 and 10), each candidate will act as ‘single hero’. He/she will take decisions and coordinate the scenario. Other candidates will act on direct orders from the team leader and should not show initiative. The team leader of Cardiac Arrest Scenarios must assign tasks to the team members i.e. he must give orders and coordinate others’ actions. 1. for airway and ventilation 2. for chest compression and defibrillation 3. for IV/IO access and drugs 4. for recording events 5. For taking care of the parents if present The team leader instructs the other team members and may take care of AB, delivers shocks or assigns another team member to do so. The team leader of Trauma Scenarios must assign tasks to the team members i.e. 1. for airway including placement of cervical collar 2. for breathing including BMV, intubation and pneumothorax decompression
3. for circulation including IV/IO access and drugs and haemorrhage control 4. for recording events 5. For taking care of the parents if present The team leader organises the team
Equipment ◆A LS manikins (size according to the scenario) (+ rhythm
simulator)
◆G loves
◆N on rebreathing masks ◆G uedel airways ◆B ag and masks ◆ I O and IV needles ◆M edications ◆N aCl 0.9% 500 ml ◆T ubes and laryngoscope + blades ◆D efibrillator + arrhythmia simulator ◆S pO2 probe
For single hero scenario: use scenarios from chapter 9 respiratory failure states and chapter 10 circulatory failure states For team work: use scenarios from chapter 11 megacodes and chapter 12 Trauma
Demo In the first scenario, the health care provider functions as ‘single hero’. In the second sequence a clear ‘team leader’ approach is demonstrated. The demos are presented in a way to diminish barriers and fear – to make the candidate at ease with the format- and to emphasize important knowledge and skills used during the scenarios. Demos are always perfect examples of how to handle a scenario. Rehearsal is always suitable before the effective demo. All scenarios are built on the rapid ABCDE assessment (see EPLS manual). The candidate receives a short clinical scenario, and a first glimpse of the patient. He/she has to ask questions to obtain additional information (for things that are not easily visible). Parameters will be available once the candidate monitors them or acts to obtain them (e.g. auscultation, blood pressure...).
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1. Weight: Broselow tape or formula [age in year + 4 ] X2 after 1 year 2. SBP Min and normal + tachycardia- bradycardia according to age 3. Normal Heart Rate, normal Respiratory Rate 4. Defibrillation in joules: 4 J/kg - cardioversion 0.5-1 J/kg 5. Adrenaline IV; IO: 10 mcg or 0.1 ml/kg 1:10,000 6. Amiodarone: 5 mg/kg (optional) 7. Fluid Bolus: 20 ml/kg 8. Tracheal tube: {Age/4} + 4 after 1 year or {Age/4} + 3.5 after 1 year if cuffed tube
2
26
Chapter 10 Teaching Scenarios and Demos
First Demo scenario
Second Demo scenario
OUTLINE 15 min
OUTLINE 15 min
At The ED, a mother brings in her 6-week old baby who has been snuffy, had a cough and been off feeds for 3 days. On examination her colour is cyanaotic and mottled. She is hypotonic.
A 8y old boy is brought in by his parents to the ED. He has been in the badroom for a long time and was unconscious when found. There is a high suspicion of CO intoxication. At first glance, the child is blue with gasping respiration – there are no other visible signs of life.
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Informations for the instructor S exhausted and obtunded A partially obstructed by copious secretions B RR 80/min W: Severe respiratory distress, T: bilateral wheezing, irregula chest rising, O: cyanosis SpO2 70% C HR 180/min, SBP 80; distal pulses weak, cold extremities, CRT 4 seconds , liver 1 cm, jugular flat.
Development This infant has bronchiolitis with decompensated respiratory failure and mild hypovolaemia. If full respiratory assessment is made, she is noted to have significantly increased work of breathing and is developing decompensated respiratory failure. She requires BMV and ultimately intubation. One bolus of 20 ml/kg crystalloid must be given to restore haemodynamics.
Interventions S Safe approach S Check responsivness S Shout for help A Open airway Suction secretions B Assess breathing by look, listen, feel and RWTO Deliver BMV with high flow oxygen Assess effectiveness of BMV C Access circulation (HR and 4 P’s) and establish shock Establish IV access, and give a fluid bolus Reassess ABCDE including AVPU, blood gases and glycaemia Ensure senior help is arriving Determine if intubation is required Key point ◆F ull ABCDE assessment through the green branch of the
EPLS algorithm
◆S ingle hero scenario with the role of helpers ◆D emo ends with a summary of the situation by the ‘candi-
date’ but NOT with a evaluation of the actions made by the candidate (this is not a GIC) and the scenario must be perfectly done (rehearsal mandatory)
Informations for the instructor ◆C ardiorespiratory arrest ◆R hythm stroke shows PEA at the first evaluation ◆A fter the first dose of adrenaline and 2 minutes
CPR, the rhythm tuns into VF defib shocks must be given before sinus rhythm reappears
◆T wo
Development The defibrillator is attached and the rhythm is evaluated. This consists of PEA. An IO is placed and a first dose of adrenaline is given followed by a flush of NaCl 0.9% . CPR is never paused. After 2’ CPR, during ventilation a VF is seen. Plan for action is made before acting. The defibrillator is charged with paddles on the defibrillator or after placement of auto-adhesive pads while continuing chest compression. Two shocks are given interposed with 2 min CPR. Intubation is performed (if experienced), ETCO2 placed, reversible causes discussed. After the second shock and 2 min CPR, the monitor shows a sinus rythm 105/’ with return of spontaneous circulation (SBP 75, Pulses palpated, CRT 4 secs. The case ends with transfer of the child to the PICU . Post cardiac arrest BP 75, HR 140/min. Opens his eyes, confused, progressive recoloration.
Intervention The instructor ‘team leader’ organises his/her resuscitation team while the ABC –CPR commences. He will himself take care of Airway and Breathing and directs all TM during resuscitation. Team Leader =TL; Team members TM 1-4. TM1 will be instructed to start with chest compressions as cardiac arrest is recognised, TM2 attaches electrodes, performs defibrillation. TM 3 prepares material for intubation, vascular access, medications, takes notes and takes care of family members etc...
European Paediatric Life Support
Discuss briefly hyperbaric oxygen and transfer to PICU Key point ◆T eam leader scenario ◆E ach team meber plays one role he/she knows. The team
leader organises the ‘ballet’.
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S Safety S Check responsiveness (TL) A Open airway (TL1) B Assess breathing by look, listen, feel (TL 1) Deliver BMV (5 breaths) with oxygen (TL 1) and give instructions C Assess signs of life and pulse (TM 1) Commence chest compression (TM 1) interponed with two breaths (TL) Attach monitor and assess rhythm (TM2) Identify VF (TL) Plan actions (TL) Place pads or attach electrodes) (TM 2) If electrodes: charge while CC is continued (TM2) Ask to remove oxygen and stop CC (TL) Give a 1st shock of 4 J/kg (TM2) Resume rapidly CPR (TM 1 + TL ) IV/IO access (TM 2 or 3) Consider 4H/4T (TL) Consider intubation + ETCO2 (TL) After 2 minutes, stop briefly CPR to check rhythm/ change rescuer Give a 2nd shock 4J/kg (TM2) Resume rapidly CPR (TM1 + TL) 3rd shock 4 J/kg (TM 2) Give adrenaline and then amiodarone (TM 3) After 2 minutes, check rhythm, verify pulse (TM 1) Start then a rapid ABCDE assessment (TL)
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◆T he scenario must be perfectly done (rehearsal mandatory)
10
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11 CHAPTER
Respiratory Failure States Case Scenarios
Scenario 6 Bronchiolitis A 6-week-old infant girl presents with a few days history of being “snuffly” and “off feeds”. On examination her colour is pale and mottled. There is audible wheezing and she is hypotonic.
Informations for the instructor
Development This infant has bronchiolitis. If full respiratory assessment is made, she is noted to have significantly increased work of breathing and is developing decompensated respiratory failure. She requires BMV and ultimately intubation. One bolus of fluid may be useful to restore haemodynamics. Interventions S Safe approach S Check responsivness S Shout for help A Open airway Suction secretions B Assess breathing by look, listen, feel and RWTO Deliver BMV with high flow oxygen Assess effectiveness of BMV C Access circulation (HR and 4 P’s) and establish shock Establish IV access, and give a fluid bolus Reassess ABCDE Ensure senior help is arriving Determine if intubation is required Key point ◆D ifferentiation between compensated and decompensated
clinical status ◆A ssessment of severity of respiratory distress/increased work of breathing (including asthma) ◆ Indications for intubation and ventilation in respiratory distress
2
Scenario 7 Epiglottitis – Compensated state – Decompensation A 4-year old boy presents with a few hours history of sore throat, dysphagia and pyrexia. On examination he is toxic, flushed and stridulous. He is sitting in his mother’s lap. Heart rate 160; Respiratory rate 40; Capillary refill time 4 seconds; Temperature 38.8°C
Informations for the instructors T° 38.8°C S conscious A partially obstructed, at risk of obstruction B RR 40/min muffled voice, respiratory distress, SpO2 88% C HR 150/min , Good pulses, CRT < 2 secs – BP should not be taken at this stage (SBP 90)
Development Any inspection of the airway, attempts to cannulate or otherwise upset the child results in immediate respiratory arrest. Appropriate initial handling of the child keeps him in steady state for some minutes: monitoring of HR and saturation and O2 by blow by accepted; topical anaesthesic on one hand; stay on Mother’s lap. However after that, the child deteriorates -Respiratory rate 10 with no stridor anymore, heart rate 90 and loss of consciousness If appropriate airway management is not immediately initiated the child becomes apnoeic, HR 40 and then deteriorates to asystole This child has epiglottitis. He has not had HIB vaccination. His conscious level deteriorates markedly during examination and his vital signs are slowing as he becomes increasingly exhausted. If this progresses to asystole, the asystole algorithm must be followed
Interventions S S A B
Safe approach Check responsiveness Assess airway and ensure patency Assess breathing (RTWO)
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S exhausted and obtunded A partially obstructed by copious secretions B RR 80/min Respiratory distress, wheezing, cyanosis SpO2 70% C HR 180/min, SBP 80; distal pulses weak, cold extremities, CRT 4 seconds, liver 1 cm, jugular flat.
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Chapter 11 Respiratory Failure States - Case Scenarios
Deliver high flow oxygen in appropriate non-threatening manner Attach SpO2 monitoring C Assess circulation HR – pulses - RCT
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Identify respiratory deterioration S Shout for help A Open airway B Assess breathing (look, listen, feel and RWTO) Deliver BMV with high flow oxygen C Assess circulation (HR & 4 Ps) Attach monitor and assess rhythm (if not already done) Establish vascular access Obtain blood samples Consider IV antibiotics (after blood for culture taken) and prepare for intubation by experienced staff member Key point ◆R ecognition and differential diagnosis in inflammatory air-
Scenario 8 Decompensated respiratory failure A 5-month old infant arrives at the ED with fever, cough and rise of the respiratory frequency. During assessment in the examination room, he becomes progressively mottled and cyanotic. Respiratory rates is rapid and shallow then decreases.
Informations for the instructor No history of choking nor trauma S Reacts to pain, obtunded A At risk B RR 70/min, shallow breath, respiratory distress decreased, symmetrical air entry on auscultation with wheeze, SpO2 60% and obvious cyanosis. C HR 200/min BP 90 good pulses, extremities fresh, CRT 3-4’’
way obstruction
◆ Initial minimalistic approach (kept with mother, no IV, sitting,
comfort, no neck/throat examination). Call for expert help. ◆E ven in obstruction BMV usually achievable with good technique (neutralised pressure limiting valve or two-hand technique). ◆E mergency intubation in epiglottitis rare. Initial management should allow for elective intubation if indicated
Development With passive oxygen, he remains desaturated, tachycardic and tachypneic and then bradypneic and bradycardic. When respiratory failure is recognised and BVM ventilation performed parameters improve before respiratory arrest occurs. Tachycardia must be treated by ventilation and oxygenation. Consider Progress to intubation If progression is adequate (first AB before to proceed to C) resuscitation is successful.
Interventions S Safe approach S Establish unconsciousness S Shout for help A open airway B Assess breathing (look, listen, feel & RWTO) Deliver bag and mask ventilation with high flow oxygen Assess effectiveness of BMV C Access circulation (HR and 4 P’s) Establish IV access Reassess ABCDE Determine necessity of intubation Call for experienced help Refer to PICU
European Paediatric Life Support
Unacceptable actions ◆N ot follow the sequence: AW opening > BMV > intubation. ◆S earching vascular access before management of airway ◆T reat bradycardia with drugs ◆T oo aggressive ventilation (observe the candidate)
Key point ◆A void flexion or hyperextension of the neck. ◆M ost cardiac arrests in childhood are of respiratory origin.
The bradycardia usually responds to good management of airway and breathing. ◆E mphasise that adequate availability of the material depends on careful tidying. Dispose of a list of equipment and precalculated medications to avoid memorisation. ◆H ow to verify tube positioning ◆D ecompression of the stomach improves ventilation
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Scenario 9 Bronchiolitis and pneumothorax (dopes) A 3-month old ex-premature with chronic lung disease is admitted for severe respiratory distress with apnoeas and desaturation during a bronchiolitis episode Improvement does not occur with simple management and the infant is intubated with an uncuffed 3.5 mm orotracheal tube. It is then installed on the ventilator. After one hour, it presents a sudden desaturation to 40 %, the ECG shows a rhythm at 180/min. The infant becomes mottled and bradycardic after a few second.
Information for the instructor
Development If the pneumothorax is not drained, the child becomes bradycardic and arrests. If adrenaline is given, the HR rises transiently (80/min). As soon as the pneumothorax is decompressed, the HR increases immediately, the saturation increases to 95% and pulses are palpable.
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A The TT is in place Tracheal suctioning does not show any plug B Air entry is diminished on the right side, which is also hyperinflated The trachea is deviated to the left side, the jugular veins are congested C When bradycardic, puses are slow and weak, extremities are cold and CRT is 4-5 sc with enlarged jugular veins
Interventions S Safe approach S Sedated S Shout for help A Observe chest movements, do direct laryngoscopy, check ETCO2 Ensure patency of TT (suction) B Ventilate the child with a bag and 100 % oxygen (RTWO) Recognise pneumothorax Insert a catheter on the right side, 2d intercostal space, mid clavicular line C Do external chest compression if bradycardic < 60/min Give adrenaline IV Review rapidly the 4H and 4T Recognise pneumothorax if not done with B Insert a catheter on the right side, 2nd intercostal
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Chapter 11 Respiratory Failure States - Case Scenarios
space, mid clavicular line Give a fluid bolus Reassess ABCDE Place a chest drain and secure Ask for Chest X-Ray. Unacceptable actions ◆N ot recognise nor drain the pneumothorax ◆P lug the cathether with a seyringe instead of free drainage
(tension pneumothorax)
◆D raining the left side
Key points ◆T he tension pneumothorax is due to air leak on high pres-
sure ventilation and provokes an obstructive shock..
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◆ It manifests as a cardiac arrest or pulseless electrical activity
progressing to bradycardia and asystole if the cause is not treated. ◆R eview DOPES ◆R eview 4 H and 4 T.
12 CHAPTER
Circulatory Failure States Case Scenarios
Scenario 10 Arrhytmia and stable patient
Unacceptable actions
A 4-month-old infant arrives to the ED. The mother reports that the child is irritable since the day before, isn’t eating properly, is sweating and is not “doing very well”
◆D o a cardioversion
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◆G ive immediately cathecholamines or drugs (haemodynam-
ic aspect does not require such an action)
Key points ◆O nly unstable rhythms require an urgent treatment (review
Informations for the instructor
Development With a non-invasive treatment, the child stays stable and definitive care should be organised (e.g. urgent cardiologist/intensivist referral). If a cardioversion is attempt, the child arrests. At that point: no further development but discuss the case.
Interventions S Safe approach S Check responsiveness A Establish airway patency B Establish breathing by RTWO Give O2 C Assess circulation by HR and 4 P’s Call cardiologist Prepare for vascular access (Adenosine) and ECG
(slow, rapid or absent). This classification doesn’t require precise knowledge of arrhythmia but is based on clinical criteria allowing to establish a treatment strategy. ◆U nderline that arrhythmia are rare in childhood and in the majority of cases they do not require an urgent treatment. ◆R eview the criteria to differentiate sinus tachycardia from supraventricular tachycardia
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T° 37°C Alert and hungry child A Stable B RR: 60/min with moderate intercostal retractions and nasal flaring, good symmetrical tidal volume; O2: SpO2 94% on ‘blow by’ oxygen C HR: 230/min; BP systolic: 80; Skin: pink, cold extremities, capillary refill: 4”; palpables peripheral pulses; liver 2 cm, jugular visible; ECG: monitoring: tachycardia, narrow complexes
criteria of unstable rhythms).
◆R eview the rhythm classification according to the pulse
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Chapter 12 Circulatory Failure States - Case Scenarios
Scenario 11 Arrhythmia in unstable patient An 2-months old baby (weight 4,5 kg) arrives in the ED. The mother says that he was well until this morning, refused the bottle and now presents with mottled skin and cyanosis. Unresponsive.
Unacceptable actions ◆A ny other medication than adenosine ◆T oo low or too high energy for the cardioversion ◆T reat the patient as a hypovolaemic shock
Crucial aspects - Key points ◆O nly unstable rhythms require an urgent treatment (review
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Informations for the instructor T° 36,7°C S Not responding to painful stimuli. A At risk B RR 60/min; Intercostal recessions, symmetrical chest rise, audible moist sounds, colour: pale, SpO2: when obtaining reading 92% C HR to fast to count, BP systolic: 50; Pulse: palpable proximal pulse, no distal pulse; Skin: cold, CRT: 5”; liver 4 cm under the rib; enlarged jugular veins; ECG monitoring: HR 260/min: Narrow complexes
Development If the treatment is adequate, the child is properly cardioverted and the supraventricular tachycardia changes to sinus rhythm. Reassess the vital signs after cardioversion. If this point is missed or if the treatment is not correct, the child will get a cardiac arrest.
Interventions S Safe approach S Establish unconsciousness S Shout for help A Open airway B Assess breathing by look, listen, feel and RWTO Start bag and mask ventilation with O2 Assess effectiveness C Assess circulation by HR and 4 P’s Install ECG and place electrodes or gel pads Do a cardioversion of 0.5 - 1 J/kg respecting safety Assess ABCDE Gain IV access Assess and transfer to PICU
Review the differences between SVT and ST
◆D escribe an unstable patient ◆R eview of the indications for cardioversion and defibrillation
and how to perform both sequences
◆R eview energy doses ◆D iscuss the usefullness of the vascular access that could
be useful but may not delay the treatment in symptomatic patient. In emergency, intraosseous access could be used. ◆ Intubation in cardiac problems is frequently indicated but is not the first or the major step of treatment.
European Paediatric Life Support
Scenario 12 Septic shock You are called by the nurse to examine a 2-year old child who has been seen the day before by a pediatrician who diagnosed a “flu”. The mother presents him to the ED because he “doesn’t look very well” and has high fever.
Informations for the instructor
Development Oxygen should be given (free flow or BVM); If tried peripheral or femoral access failed When I.O. is successfully placed, a first fluid bolus (20 ml/ kg) is given quickly. The patient must be reassessed. A second bolus of fluid and a third along with catecholamines should be given before normalisation of parameters Blood samples results when IO placed: pH 7.10, pCO2 35 mmHg, PaO2 140 mmHg, BE –15, glycaemia 35 mg/dl
Interventions S Safe approach S Establish unconsciousness S Shout for help A Open airway B Assess breathing (look, listen, feel & RWTO) Oxygen by mask or bag and mask ventilation Assess effectiveness C Access circulation (HR and 4 P’s) and establish shock Establish IV /IO access, do blood sampling, give AB and give 1st fluid bolus Reassess C Administer 2d fluid bolus Reassess C and give fluid as appropriate Administer vasoactive drug Assess ABCDE, discuss intubation, consider possible causes of shock in these circumstances and refer on for definitive diagnosis
Unacceptable actions ◆D elay the treatment to perform blood sampling ◆T reat as an arrgythmia ◆U se a non-isotonic fluid ◆U se too small bolus of fluid
Crucial aspects - Key points ◆S hock diagnosis ◆ IO technique
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T° 39C° S The child reacts only to pain. A At risk B RR 24/min; shallow, symmetrical; no recession, pale, no central cyanosis, SpO2: no signal C HR: 190/min; BP systolic 55; Central pulses: weak, peripheral pulses not palpable; cold extremities, CR 5’’ Presence of petechiae on the thorax and the neck.
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Chapter 12 Circulatory Failure States - Case Scenarios
Scenario 13 Anaphylactic shock A 5-year old girl complained of feeling unwell after receiving aspirin for headache. She developed generalised urticaria, swelling of the lips, abdominal pain and diarrhoea. She then became flushed, with obvious facial oedema, generalised urticaria and “noisy breathing”. She arrives in the Emergency Department (ED)
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Informations for the instructor S drowsy A Partially obstructed B RR 45/min; Laboured breathing, stridor, generalised bilateral wheezing on auscultation, SpO2: 92% C HR 150/min; BP: 70/40 distal pulses weak, proximal present, warm extremities, CRT< 1’’ The child is known to be allergic to a number of foods. She is a known asthmatic. It is the first time she received aspirin One dose of IM adrenaline, a bolus of crystalloid (not colloid) should also be given Expert help for difficult intubation and senior intensivist must be sought early
Interventions S Safe approach S Check responsivness S Shout for help S Ask for expert help A Assess airway and ensure patency B Assess breathing by look, listen, feel and RWTO Deliver high flow oxygen by appropriate facemask (BMV if appropriate) Administer IM adrenaline 150 mcg Assess effectiveness C Assess HR and 4 P’s Attach monitor and assess rhythm Establish vascular access Obtain blood samples Administer 1st fluid bolus Reassess C Consider further adrenaline and other medications (antihistamine and steroids) within anaphylaxis algorithm Transfert to PICU once stabilised Key point ◆D ifficult airway management ◆D iscuss adrenaline injection during ‘Breathing ‘ ◆A naphylaxis protocols ◆D ifferent types of shock (e.g.
Scenario 14 Hypovolaemic shock: gastroenteritis You are examining a 6-month old girl who is vomiting and presents with diarrhoea for 2 days. She looks dehydrated with dry mucosae.
Informations for the instructor S Does not recognise her parents and reacts barely to pain A at risk but not obstructed B RR 50/min, no increased work of breathing, normal pulmonary auscultation, pale, SpO2: difficulty to obtain, when readable 96% C HR 180/min; BP systolic: 60 mm Hg; weak proximal pulses; Absence of distal pulses; cold extremities, CRT: 5’’, no signs of increased preload ECG Narrow regular QRS complexes
Development Peripheral line insertion failed, oral feeding impossible but IO placement succeeded. When vasculars access is placed and 2 fluid boluses of 20 ml/kg crystalloid given, the child becomes conscious, peripheral pulses are palpable during the rest of the resuscitation. If venous access is not attempted, fluid bolus is not administrated or only peripheral access is attempted but failed, the patient will arrest.
Interventions S Safe approach S Establish unconsciousness S Shout for help A Establish airway patency B Assess breathing (look, listen, feel & RWTO) Free flow oxygen or bag and mask ventilation Assess effectiveness C Access circulation (HR & 4 P’s) Place monitoring Recognise shock Establish IO access 1st Fluid bolus of fluid (crystalloid) Reassess C Administer 2nd bolus of isotonic fluid Reassess C Assess ABCDE Consider possible causes of shock in these circumstances Refer on for definitive diagnosis
European Paediatric Life Support
Unacceptable actions ◆T reat HR as an arrhythmia (by drugs or electrical cardioversion ◆ Intervention on airways (except oxygen administration) ◆U sing non isotonic fluid ◆N ot enough or too slow bolus of fluid ◆W aste time for peripheral infusion placement.
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Scenario 15 Hypovolaemic shock: gastroenteritis
Key points
A 16-months-old-child is admitted in the ED presenting watery diarrhoea and vomiting. She is sleepy and do not eat any more.
◆T ables for normal blood pressure in children. ◆M easurement of the BP is not always reliable in children
Information for the instructor
so that it could be better to assess the organs perfusion to decide if the patient is or is not in a shock state (mottled skin, pulse amplitude, consciousness). ◆T he BP and consciousness allows tdifferentiation between compensated and decompensated shock states
Development After O2 administration and monitoring placement, a IV line is placed. After one bolus 20 mls/kg of crystalloids, the child is reassessed. HR 180/min. Skin perfusion: CRT 4”. Peripheral pulses: weak, no signs of increased preload A second bolus must be given to normalise the parameters.
Interventions S Safe approach S Establish unconsciousness S Shout for help A Open airway B Assess breathing (look, listen, feel and RWTO) Free flow oxygen or bag and mask ventilation Assess effectiveness C Access circulation (HR & 4 Ps) Place monitoring Recognise shock Establish IV/IO access 1st Fluid bolus of fluid (crystalloid) Reassess C Administer 2nd bolus of isotonic fluid Reassess C Assess ABCDE Consider possible causes of shock in these circumstances Refer on for definitive diagnosis
Personal copy of Lilianna STYKA (ID: 18280)
T° 36,3°C S Does not recognise her parents and reacts barely to pain A At risk B RR 65/min, no increased work of breathing, normal pulmonary auscultation, no cyanosis, pale C HR 200/min; BP systolic: 60 mm Hg; Weak proximal pulses; absent distal pulses; cold extremities, CRT: 5’’, no signs of increased preload ECG Narrow regular QRS complexes
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Chapter 12 Circulatory Failure States - Case Scenarios
Unacceptable actions ◆T reatment of rhythm by drug or cardioversion ◆T oo small or too slow bolus of fluid ◆U se of inotropes instead of fluid ◆A dminiqtration of bicarbonate or glucose instead of bolus
of crystalloids.
Scenario 16 Hypovolaemic shock: peritonitis A 4-year old boy has had abdominal pain and fever for the last 24 hours. The child is delirious and drowsy. ◆H eart rate 165/min; Respiratory rate 30/min; CRT 4-5 seconds; ◆B lood pressure 70/30; Temperature 38.2°C
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Informations for the instructor T° 38,2 °C S Drowsy A At risk but clear B RR 30/min, quiet, good symmetrical chest rise, SpO2 97% C HR 165/min; BP 65/30; Peripheral distal pulse weak, CRT 4-5’’, cold extremities, liver at edge of costal margin, flat jugular veins
Development This child has peritonitis secondary to acute appendicitis. He has decompensated hypovolaemic shock. There is minimal improvement with oxygen via a face mask. Hypovolaemic circulatory failure necessitates repeated fluid boluses and consideration of inotropic support. Surgeon must be called.
Interventions S Safe approach S Establish responsivness S Shout for help A Establish airway patency B Assess breathing (look, listen, feel & RWTO) Oxygen or bag and mask ventilation Assess effectiveness C Access circulation (HR and 4 Ps Recognise shock Establish IV access (blood sample) Attach monitor and assess rhythm Give a 1st Fluid (crystalloid) Reassess C Administer a 2nd bolus of isotonic fluid Reassess ABCDE Consider antibiotics, further boluses and inotropes Consider causes of shock in these circumstances Refer on for definitive diagnosis (surgeon)
13 CHAPTER
Cardiac Arrest - Megacodes Team Work - Case Scenarios
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Information to the Instructor and/or Course Director: In this session at least one scenario of shockable CA, one on asystole and on PEA should be done.
A 6 month old infant is brought in the emergency department with a history of severe bronchiolitis and rapid deterioration. While taking over, the infant becomes cyanotic and loses consciousness.
Information for the instructor No fever A Obstructed head tilt/chin lift ineffective, must be open by jaw thrust B Apnoeic (With BMV: air entry is symmetrical with moist sounds; Oxygenation: cyanotic, SpO2: not detectable) C No signs of life; HR = asystole; central pulses absent
Intervention S Safety S Check responsiveness S Shout for help A Open airway B Assess breathing by look, listen, feel Assign tasks to the team Deliver BMV (5 breaths) with oxygen – ensure chest rise C Assess signs of life and pulse Commence chest compression Attach monitor and assess rhythm Identify asystole appropriately Establish vascular access (IO) Administer adrenaline 10 mcg/kg IV Consider treatable causes Continue with non-shockable algorithm until signs of life appear or a pulse is palpable Start a rapid ABCDE assessment Consider intubation – Transfer to PICU
Development
Unacceptable actions
The child is in cardio-respiratory arrest (asystole). When the child is correctly ventilated with BVM, there are no signs of life. If pulse is felt for (femoral or brachial; no more than 10 secs), it is absent. Chest compression is started. Vascular access is performed (IO after failure of peripheral line) and adrenaline given. The child regains spontaneous circulation after correct ventilation, ECC and 1 dose of adrenaline. Intubation may be considered after ROSC.
◆N o ABC ◆N o reassessment after each action
Key points ◆R eassess after each action ◆A ssign tasks to the team (when, how, how many) ◆C heck rhythm after 2 min CPR ◆A drenaline every 2 loops ◆D iscuss briefly post arrest care
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Scenario 17 Bronchiolitis and cardiorespiratory arrest
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Chapter 13 Cardiac Arrest - Megacodes - Team Work - Case Scenarios
Scenario 18 Pneumonia – cardiorespiratory arrest A 4 year-old infant boy was seen in A&E yesterday with pneumonia. He was discharged home as he appeared to be coping well but his parents have rushed him back to the hospital, as his effort on breathing has markedly increased. On their way, in the car he “turned blue and stopped breathing”. In your hospital parents are allowed to be present during every procedure.
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Informations for the instructor No fever A At risk B RR: apnoeic, W: none; T: symmetrical with BMV; O: cyanotic, SpO2: not detectable C No signs of life BP = none; pulses absent, ECG: sinus bradycardia – 30 / min
Additional instructor’s Information This infant is in cardiorespiratory arrest as a result of hypoxia Despite effective BMV technique the baby remains ‘stiff’ and difficult to ventilate necessitating depressing the pressure-Iimiting valve to achieve adequate chest movement and/or two-hand mask and bag ventilation. One candidate must be assigned to stay with the parents and explains the procedure He becomes asystolic until an intraosseous cannula is sited and 2 cycles of adrenaline and CPR have been delivered Intubation is ultimately required and IPPV started
Intervention S Safety S Check responsiveness S Shout for help A Open airway B Assess breathing by look, listen, feel Assign tasks to the team Deliver BMV (5 breaths) with oxygen – ensure chest rise C Assess signs of life and pulse Commence chest compression Attach monitor and assess rhythm Identify asystole appropriately
Establish vascular access (IO) Administer adrenaline 10 mcg/kg IV
Consider treatable causes Continue with non-shockable algorithm until signs of life appear or a pulse is palpate Start a rapid ABCDE assessment Consider intubation – Transfer to PICU Key points ◆P resence of family members. ◆T eam approach ◆D iscontinuation in prolonged arrest situations ◆A dditional points to be demonstrated as appropriate to
the scenario
◆S ummoning experienced senior assistance ◆C heck rhythm every 2 minutes ◆R eferral for definitive management
European Paediatric Life Support
Scenario 19 Cardiac arrest in intubated child The mobile emergency unit brings in a 6 Kg infant. The infant was intubated for respiratory distress. During the transfer a cardiac arrest occurred. The infant is brought in with a severe bradycardia (HR 30/min) on the monitoring and no IV access.
Informations for the instructor ◆S ymmetrical
Development If the treatment is correct (evaluation of the airway, ventilation, chest compressions), diagnosis of oesophageal intubation is made. The ECG shows a sinus bradycardia with signs of poor perfusion. If the treatment was not adequate, there is no restoration of a sinus rhythm and the patient is not resuscitated.
Interventions S Safety S Check responsiveness S Assign tasks to the team A Assess airway by auscultation, direct laryngoscopic view or remove tube B Assess breathing Remove tube and deliver BMV (5 breaths) with oxygen – ensure chest rise C Assess signs of life and pulse Commence chest compression if necessary Establish vascular access (IO) Establish intubation necessity Call a senior Re-intubation Verify – attach tube Check ABCDE according to the rapid ABCDE assessment Transfer to PICU
Unacceptable actions ◆R etry venous access first before checking the airway ◆D efibrillation, cardioversion, give calcium ◆N o clinical reassessment
Key points ◆ Importance of clinical evaluation before each action, give
examples where lack of evaluation may lead to potential damage to the patient. ◆T reatment of arrhythmias is based on clinical criteria. ◆A irway management is crucial in the treatment of arrhythmias. ◆D OPES
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respiratory sounds, normal thoracic excursions ◆V isualisation of tracheal tube not passing the vocal cords ◆ I V line insertion failed ◆N o signs of life, very slow cardiac noises
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Chapter 13 Cardiac Arrest - Megacodes - Team Work - Case Scenarios
Scenario 20 Drowning – cardiorespiratory arrest A 2 year old child is found in the neighbour’s swimming pool after 10 minutes after being missed by his parents. It is the winter season. A witness pulls him rapidly out of the water and starts CPR. You are arriving with a mobile emergency unit.
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Informations for the instructor A At risk B No spontaneous respiratory movements C No signs of life or pulse ECG: HR- 30/min large complexes T°: 33°C
Development With bag/mask ventilation, chest movement is present but the abdomen swells up, HR stays 40/min. After ECC commenced, the HR rises to 50/min and saturation rises to 95 %. HR> 80 /min after one dose of adrenaline. The BP remains in the low 60 mm Hg if in the absence of vascular access and volume resuscitation. Discuss indication of rewarming.
Intervention S Assign tasks to the team (before arriving on site) S Safety S Check responsiveness A Open airway B Assess breathing by look, listen, feel Deliver BMV (5 breaths) with oxygen – ensure chest rise C Assess signs of life and pulse Commence chest compression Attach monitor and assess rhythm Identify bradycardia Establish vascular access (IO) Administer adrenaline 10 mcg/kg IV Check temperature as part of 4Hs & 4Ts Consider intubation Place gastric tube Consider treatable causes Continue with asystole algorithm until signs of life appear or a pulse is palpated Start then a rapid ABCDE assessment Undress and maintain T° between 32 and 34°C Transfer to PICU
Unacceptable actions ◆E very manoeuvre to empty the stomach (any type of hand
compressions of the epigastric zone)
◆D elay in intubation ◆D efibrillation without VF ◆T ime lost by trying peripheral infusion
Key points ◆A BC is the priority in submersion victims ◆N ecessity of rapid intubation because of the risk of pulmo-
nary oedema and compliance modification in the submersion victims ◆A nticipate the risk of vomiting and aspiration. (> 85% of cases) ◆H eimlich manoeuvre is not indicated! ◆C ervical protection only with diving accident or visible neck lesions! ◆R eview briefly hypothermia specificity
European Paediatric Life Support
Scenario 21 Cardiac child in ventricular fibrillation A 4 year old is known with a long QT syndrome. He suddenly falls back during shopping with his mother in a hypermarket, while he was completely normal just seconds before. A witness starts immediate mouth-tomouth and chest compressions. The mobile emergency unit arrives within 8 minutes. Three persons are on board.
Informations for the instructor ◆C ardiorespiratory arrest ◆R hythm stroke shows VF
Stabilisation sinus rhythm after 3 defibrillations + one dose of Adrenaline + one dose of Amiodarone. Post cardiac arrest BP 75, HR 140/min Opens his eyes, confused, progressive recovery.
Intervention S Assign tasks to the team (before on site arrival) S Safety S Check responsiveness A Open airway B Assess breathing by look, listen, feel Deliver BMV (5 breaths) with oxygen – ensure chest rise C Assess signs of life and pulse Commence chest compression Attach monitor and assess rhythm Identify VF Plan actions choose paddles or attach pads If pads: charge while CC is continued Ask to remove oxygen and stop CC Give a 1st shock of 4 J/kg Resume rapidly CPR IV/IO access Consider 4H/4T Consider intubation After 2 minutes, stop briefly CPR to check rhythm/ change rescuer Give a 2nd shock 4J/kg Resume rapidly CPR 3rd shock 4 J/kg Give adrenaline and then amiodarone After 2 minutes, check rhythm, verify pulse Start then a rapid ABCDE assessment Transfer to ambulance
Unacceptable actions ◆N o identification of the rhythm ◆N o defibrillation ◆C ardioversion instead of defibrillation ◆N o adrenaline ◆ Lose time with intubation, vascular
access before defibrillation Key points
◆D ifferences between paediatric arrest and adult arrest,
arrest in children with known cardiopathy and witnessed collapse in children. ◆ Importance of defibrillation in this type of patients ◆R eview defibrillation safety ◆E mphasize to minimise interruptions of CC ◆D iscuss indications of post- CA hypothermia
Personal copy of Lilianna STYKA (ID: 18280)
Development
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Chapter 13 Cardiac Arrest - Megacodes - Team Work - Case Scenarios
Scenario 22 Cardiac child in ventricular fibrillation You are called to the Outpatients Department where a 7-year old boy has collapsed. A nurse is delivering basic life support when you arrive. The child has a sternotomy scar on his chest.
Give adrenaline and then amiodarone After 2 minutes, check rhythm, verify pulse Start then a rapid ABCDE assessment Transfer to PICU Key point ◆S afe defibrillation ◆S hockable rhythms rare in children but devastating if missed
and not treated early
Informations for the instructor
Personal copy of Lilianna STYKA (ID: 18280)
◆E ffective
BVM technique results in good bilateral chest expansion. ECG monitor displays ventricular fibrillation ◆H e remains in ventricular fibrillation until after 3 defibrillation shocks and 1 dose of adrenaline have been delivered. ◆V ascular access is only achieved via intraosseous route
Additional lnstructor Information The child has a congenital cardiac condition and is in cardiorespiratory arrest
Intervention S Safety S Check responsiveness S Shout for help A Open airway B Assess breathing by look, listen, feel Assign tasks to the team Deliver BMV (5 breaths) with oxygen – ensure chest rise C Assess signs of life and pulse Commence chest compression Attach monitor and assess rhythm Identify VF Plan actions Choose paddles or attach pads If pads: charge while CC is continued Ask to remove oxygen and stop CC Give a 1st shock of 4 J/kg Resume rapidly CPR IV/IO access Consider 4H/4T Consider intubation After 2 minutes, stop briefly CPR to check rhythm/ change rescuer Give a 2nd shock 4J/kg Resume rapidly CPR 3rd shock 4 J/kg
◆H igh index of suspicion in post-operative cardiac children ◆S ummoning experienced senior assistance ◆R eferral for definitive management ◆A ppropriate care of family members
European Paediatric Life Support
45
Scenario 23 Child with pulseless electrical activity A 5-year old boy in renal failure had a cardiac arrest on the ward. Basic life support was initiated by the ward nurses. On arrival of the cardiac arrest team the child is apnoeic and pulseless.
Information for the instructor ◆E CG
Development This child is in cardiorespiratory arrest secondary to hyperkalaemia. The broad ORS complexes normalise and cardiac output returns with calcium and bicarbonate administration.
Intervention S Safety S Check responsiveness A Open airway B Assess breathing by look, listen, feel Assign tasks to the team Deliver BMV (5 breaths) with oxygen – ensure chest rise C Assess signs of life and pulse Commence chest compression Attach monitor and assess rhythm Identify PEA appropriately Establish vascular access (IO) Administer adrenaline 10 mcg/kg IV
Personal copy of Lilianna STYKA (ID: 18280)
monitor shows broad ORS complexes at a rate of 130/minute There is no central pulse ◆C ardiac output only returns after full ALS with adrenaline and consideration of possible causes ◆S erum potassium is 8.5 mmol/L ◆S pontaneous circulation returns with measures to reduce potassium (do not dwell on specifics)
Consider treatable causes Continue with PEA algorithm until signs of life appear or a pulse is palpate Start a rapid ABCDE assessment Consider intubation – Transfer to PICU Key point ◆P otential treatable causes of PEA ◆D oses: Calcium chloride 0.2 mEq or ml/kg and Bicarbonate
8.4% 1 mEq or ml/kg
13
Personal copy of Lilianna STYKA (ID: 18280)
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Chapter 13 Cardiac Arrest - Megacodes - Team Work - Case Scenarios
14
Trauma - Case Scenarios
47
CHAPTER
Scenario 24 Airway management in trauma patient You get a call from the emergency room: a 6 year-old boy is brought in by his father, fallen from a staircase. When he arrives, there are no external signs except from a left parietal haematoma.
S The boy does not respond to speech nor stimulation to but only to pain. A At risk because of conscious level , no blood in the mouth, supraglottic region free of debris No facial lesions, no lesions of the upper airways, B Breathing is slow and irregular, breathing sounds are weak but symmetrical, no good thoracic movements, cyanosis, SpO2: 80%. No midline deviation of the trachea, no distension of jugular veins C HR 70/min, SBP 85, mottled, pulses palpables, extremities slightly cold, CRT 3’’ D Pupils are 3 mm bilaterally, reactive to light E no other injury visible
Attach monitor and assess rhythm Place two IV access (blood sampling including group and order PRBC) Reassess ABC D Assess AVPU + Pupils E Undress and examine
Establish necessity of intubation Call for senior. Oral Intubation Assess right position of TT and tape
Immobilise C-spine, transfer on spine board and immobilise Unacceptable actions ◆N ot following the right order of actions: inline stabilisation
with neutral positioning, then opening of the airway, then bag mask ventilation ◆G oing over to circulation without having established good ventilation ◆U sing drugs to treat bradycardia ◆N o tube fixation, no inline stabilisation after intubation ◆N o immobilisation on a board before transport Key points
◆O pening the airways (A) and ventilation (B) has higher pri-
Development If there is adequate opening of the airway and restoration of ventilation, the child becomes pink again, cardiac rhythm normalises, spontaneous breathing will reoccur with spontaneous movements. If not, the rhythm will progresse to asystole. Cervical stabilisation is mandatory.
Intervention S S S
Safety Check responsiveness Shout for help
Assign tasks to the team A Open airway with jaw thrust and in-line stabilisation B Assess breathing (look, listen & feel; RWTO) Bag and mask ventilation with 02 Search for pneumothorax Reassess B C Assess circulation (HR + 4 Ps) Establish absence of external haemorrhage & shock
orities than protecting the cervical spine: the most frequent cause of airway obstruction in the comatose child, is the relatively large tongue, obstructing the hypopharynx ◆ Intubation should be achieved without extension of the head if possible ◆D uring tube fixation, cervical protection must continue ◆H ighlight the fact that respiration might be insufficient without signs of increased work of breathing (for instance hypoventilation in neurotrauma, meningitis, convulsions or intoxication)
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Information for the instructor
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Chapter 14 Trauma - Case Scenarios
Scenario 25 Trauma and pneumothorax A 7-year old boy has been hit by a car whilst playing on the road. There is no C- spine immobilisation on arrival in the ED.
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Informations for the instructor S Unresponsive to pain. A Obstructed by tongue B RR 6 Increased work of breathing, hypoventilation on left side, asymmetrical chest rise, cyanosis, jugular veins turgescent, trachea deviated to the right side SpO2 60% C HR 165; BP 60/-; Distal pulse very weak, proximal pulse weak, mottled and cold extremities, Capillary refill time 6 seconds; no liver palpable, enlarged jugular veins.
Development This boy has had a major head injury and left tension pneumothorax. His reduced conscious level has caused airway obstruction with resultant hypoventilation and hypoxia. The hypoxia is exacerbated by the tension pneumothorax. Following C-spine immobilisation and airway opening with Guedel airway insertion, BMV results in good air entry on the right side only. Colour and saturation slightly improve (70 %) but only normalise after the tension pneumothorax is relieved by needle thoracocentesis. After Pneumothorax decompression, HR is 155, SBP is 70. A bolus of fluid must be given. There is no improvement in the conscious level and expert assistance will be required for RSI, intubation and CT scan.
Intervention Assess for other injuries Intubation and gastric tube Transfer on spine board. Refer on for definitive diagnosis S S S
Safety Check responsiveness Shout for help
Assign tasks to the team A Open airway with jaw thrust and in-line stabilisation B Assess breathing (look, listen & feel; RWTO) Bag and mask ventilation with 02 Search for pneumothorax. Recognise pneumothorax Insert a catheter on the right side, 2d intercostal
space, mid clavicular line Reassess B C Assess circulation (HR + 4 Ps) Establish absence of external haemorrhage Establish the presence of shock Attach monitor and assess rhythm Place two IV access (blood sampling including group and order PRBC) Give a 1st fluid bolus Reassess ABC D Assess AVPU + Pupils Establish the necessity of urgent CT-Scan E Undress and examine Place an orogastric tube Call for a expert senior if not already done. Establish the necessity of chest drainage Place the drain and secure the tube. Establish necessity of intubation. Oral Intubation. Assess right position of TT and tape Immobilise C-spine, transfer on spine board and immobilise Transfer to CT-scan once stabilised
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Scenario 26 Trauma and hypovolemic shock A 10 year-old child has fallen from a balcony on the third floor (about 10 m). He fell on both his feet, followed by a forward fall. When the ambulance crew arrived, he was conscious and complaining of pain on his left leg, his back and both his arms. He is brought in with oxygen by nasal tube, a soft cervical collar has been placed but his head is not in line immobilised. A cervical spine board is not applied, there is no vascular access.
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Give a 1st fluid bolus Reassess ABC D Assess AVPU + Pupils E Undress and examine Immobilise C-spine, transfer on spine board and immobilise Discuss best radiological examination to perform (3 X-Rays or CT scan or MRI?)
Information for the instructor
Development Cervical inline stabilisation must be performed first: proper position of the head, rigid collar, before to proceed to other action O2 administration with mask Two peripheral venous accesses with blood sample (cross match, …) Placement of monitor. A single bolus of fluid is required. Reassess the effect of your fluid bolus. Pupils are equal and normally reactive to light. The child is conscious and responds adequately. Undress the child
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S Conscious, in pain A Free, trachea in midline B RR 40/min, Slight recession, symmetrical chest rise, good air entry except decreased air entry on the left lung basis; pink, SpO2 90% C HR 150/min; BP 80/40, peripheral distal pulse weak, cold extremities, CRT 4’’, jugular veins not visible
Intervention S Safety S Check responsiveness S Shout for help Assign tasks to the team A Establish patency In-line stabilisation of the C-Spine B Assess breathing (look, listen & feel; RWTO) 02 with non-rebreathing mask Search for pneumothorax. Assess effectiveness C Assess circulation (HR + 4 Ps) Establish absence of external haemorrhage Attach monitor and assess rhythm Establish the presence of shock Place two IV access (blood sampling including group and order PRBC)
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Chapter 14 Trauma - Case Scenarios
Scenario 27 Trauma and shock A 2-years and 3 months-old boy baby has had an accident on a public road. He was seated in the back of a car. When the car was hit, the child was ejected 20 m away. He was found in prone position, without spontaneous movements. There is no external blood loss.
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Information for the instructor S unconscious A At risk, trachea in midline B RR 10/min, Recessions, symmetrical chest rise and murmur, cyanosis, SpO2 70% C HR 180/min; SBP 60; Cold extremities, CRT 5’’; Distal peripheral pulses absent, proximal pulses present; Jugulars not congested D Only responds to painful stimulation. Pupils symmetrical and reacting Head trauma, multiple fractures, no external hemorrhage
Establish the presence of shock Place two IV access (blood sampling including group and order PRBC) Give a 1st fluid bolus Reassess ABC Establish the necesity of a second bolus of fluid Give a second bolus of fluid Reassess ABC D Assess AVPU + Pupils Establish the necessity of urgent CT-Scan E Undress and examine Place an orogastric tube Establish necessity of intubation. Oral Intubation. Assess right position of TT and tape Immobilise C-spine, transfer on spine board and immobilise Call the neurosurgical unit and transfer once stabilised Crucial aspects – Key points ◆R espect the ABC + cervical inline stabilisation with primary
Development The candidate must log roll the child on his back on a spinal board (this will require 4 persons: 1 for the head and neck, one for the torso, and the pelvis and finally one for the legs) The airway is open with jaw thrust manœuvre, keeping the head inline. The child turns pink when BMV is being administered. Two venous cannulae are inserted and blood sample is taken. After first fluid bolus, HR is 165/ Min, SBP 70, cold extremities, CRT 4’, distal pulses weak. A second bolus of fluid normalises haemodynamics (HR 120/min, SBP 80, warm extremities, CRT 2’’. An oral gastric tube could be inserted (gastric fluid clear). After neurologic assessment the patient may be intubated.
Intervention S Safety S Check responsiveness S Assign tasks to the team before arrival A Open airway with jaw thrust and in-line stabilisation Turn the child on his back with a 4 person log roll B Assess breathing (look, listen & feel; RWTO) Bag and mask ventilation with 02 Search for pneumothorax. Establish absence of pneumothorax Assess effectiveness of BMV C Assess circulation (HR + 4 Ps) Establish absence of external haemorrhage Attach monitor and assess rhythm
and secondary survey
◆D iscuss hypovolaemic shock signs and treatment ◆D iscuss Head injury ◆ Is head injury responsible for hypovolaemic shock (Scalp
haematoma and subdural haematoma)
◆S igns and treatment of RICP
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BLS Evaluation Sheet: formal evaluation
INSTRUCTORS
/
NAME
FIRST NAME
Please, give back the evaluation sheet to your course director
RESULT INTERVENTIONS Do a safe approach
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Stimulate the child w.o shaking Shout for help Open airway according to the age of the child with the universal manoeuvre Perform Look, Listen, Feel (10 sec) Give 5 Breaths (50 % give an adequate chest rising) Search signs of life (may add pulse palpation: carotid or bracchial according to age) Is able to perform adequate chest compressions Landmarks (xiphoid) Depth at least 1/3 Ratio 15:2 Rate 100-120/min Adequate transition between breaths and CC Seek for help after one minute of BLS and give adequate information The sequence is adequate COMMENTS
Succeed COMPETENT
Fail
Retest
NOT (YET) COMPETENT: to improve
BLS Evaluation Sheet: continuous evaluation INSTRUCTORS
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/
NAME
FIRST NAME
Please, give back the evaluation sheet to your course director
INTERVENTIONS
COMPETENT
NOT (YET) COMPETENT: to improve
Do the full sequence adequately Stimulate the child w.o shaking
Is able to perform correct insufflations (50 % give an adequate chest rising) Is able to perform adequate chest compressions (Landmarks, depth at least 1/3, ratio 15:2, rate and adequate transition between breaths and CC) COMMENTS
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Is able to correctly open the airway according to the child’s age
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Candidate Portfolio
COURSE DATE NAME COURSE DIRECTOR
BLS BABY DEMONSTRATION
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BLS BABY DEMO COMMENT BLS CHILD DEMONSTRATION BLS CHILD DEMO COMMENT BLS WORKSHOP A - Airway opening, OPA / NPA, suction BMV and CPR with BMV A - Choking, C-spine care, recovery position if no second station of BLS B- Respiratory failure: oxygen delivery – intubation (aids); ETCO2 – pulse oximetry – tension pneumothorax C- Circulatory failure: umbilical / Intraosseous access; fluids and medication, massive transfusion Defibrillation, cardioversion (+/- AED) skill station CARDIAC ARREST ALGORITHM ARRHYTHMIA ALGORITHM
FIRST NAME
Candidate Portfolio
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COURSE DATE
Post-cardiac arrest resuscitation care NEONATAL DEMO NEONATAL SCENARIOS Personal copy of Lilianna STYKA (ID: 18280)
SCENARIO DEMO “INSTRUCTOR” Single hero scenario / Team work scenario SCENARIO DEMO “CANDIDATE” Single hero scenario / Team work scenario RESPIRATORY FAILURE SCENARIOS SCENARIOS TRAUMA SCENARIOS CIRCULATORY FAILURE SCENARIOS MEGACODE - CARDIAC ARREST CRITICALLY ILL CHILD LECTURE NEWBORN RESUSCITATION LECTURE TRAUMA CHILD LECTURE
INSTRUCTOR’S SIGNATURE
COURSE DIRECTOR’S SIGNATURE
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Contact details European Resuscitation Council Drie Eikenstraat 661 - 2650 Edegem - Belgium
[email protected] - www.erc.edu
www.erc.edu
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