Initial Assessement

Airway

  • Provide 100 percent inspired oxygen
  • Allow the child to assume a position of comfort or manually open the airway
  • Clear the airway (suction)
  • Insert an airway adjunct if consciousness is impaired (eg, nasopharyngeal airway or, if gag reflex absent, oropharyngeal airway)
  • If the patient is unresponsive without signs of life, begin chest compressions immediately

Breathing

  • Assist ventilation manually in patients not responding to basic airway maneuvers or with inadequate or ineffective respiratory effort
  • Monitor oxygenation by pulse oximetry
  • Monitor ventilation by end-tidal carbon dioxide (EtCO2) if available
  • Administer medications as needed (eg, Salbutamol for status asthmaticus, inhaled racemic epinephrine for croup)

Circulation

  • monitor heart rate, rhythm, and establish vascular access
  • Access shock

Shock

  • PALS Definition of hypotension
    • Term neonates (0 to 28 days): <60 mmHg
    • Infants (1 to 12 months): <70 mmHg
    • Children (1 to 10 years): <70 mmHg + (child's age in years x 2)
    • Children >10 years: <90 mmHg

Types of shock

  • Hypovolemic
  • Distributive
  • Cardiogenic
  • Obstructive

Disability

  • AVPU pediatric response scale: Alert, Voice, Pain, Unresponsive
  • Pupillary response to light
  • Presence of hypoglycemia (rapid bedside glucose or response to empiric administration of dextrose)
  • Glasgow Coma Scale: Eye Opening, Verbal Response, Motor Response (for trauma patients)

Second Assessment

This portion of the evaluation includes a thorough head to toe physical examination, as well as a focused medical history that consists of the "SAMPLE" history:

  • S: Signs and symptoms
  • A: Allergies
  • M: Medications
  • P: Past medical history
  • L: Last meal
  • E: Events leading to current illness

Cardiopulmonary failure

  • Respiratory failure and hypotensive shock are the most common conditions preceding cardiac arrest.

Causes of respiratory failure include:

  • Upper airway obstruction (choking, infection)
  • Lower airway obstruction (asthma, foreign body aspiration)
  • Parenchymal disease (pneumonia, acute pulmonary edema)
  • Disordered control of breathing (coma, toxic ingestion, status epilepticus)

Causes of hypotensive shock include:

  • Hypovolemia (dehydration, hemorrhage)
  • Cardiac failure (eg, due to myocarditis or valvular disease)
  • Distributive shock (septic, neurogenic)
  • Metabolic/electrolyte disturbances
  • Acute myocardial infarction/ischemia
  • Toxicologic ingestions
  • Pulmonary embolism

Bradycardia

Signs of sinus bradycardia

  • slowing of heart rate relative to normal values
  • PR interval normal
  • in healthy children

Signs of pathogenic bradycardia

  • Slow heart rate relative to normal rates
  • P waves that may or may not be visible
  • QRS complex that is narrow (electrical conduction arising from the atrium or high nodal area) or wide (electrical conduction from low nodal or ventricular region)
  • P wave and QRS complex may be unrelated (ie, atrioventricular dissociation) or have an abnormally long period between them (atrioventricular block)

Tachycardia

Signs of sinus Tachycardia

  • Heart rate is usually <220/min in infants, <180/min in children, and exhibits beat to beat variability in rate.
  • P waves are present with normal appearance.
  • PR interval is constant and exhibits a normal duration for age.
  • R-R interval is variable.
  • QRS complex is narrow.

Pathogenic tachycardia

SVT

  • Heart rate that is usually >220/min in infants, >180/min in children, and has no or minimal beat to beat variability.
  • P waves are absent or abnormal.
  • PR interval may not be present or short PR interval with ectopic atrial tachycardia.
  • R-R interval is usually constant.
  • QRS is usually narrow. Conduction delay along the ventricular system may lead to an appearance of wide complex tachycardia, known as SVT with aberrant conduction.

VT

  • Ventricular rate is >120 beats per minute and regular.
  • P waves are often not identifiable, may have AV dissociation, or may have retrograde depolarization.
  • QRS is typically wide (>0.09 seconds).
  • T waves are often opposite in polarity from the QRS complex.