American AMERICAN Heart ‘ASSOCIATION Associations ‘CRITICAL-CARE _ NURSES life is why PALS Vital Signs in Children Normal Respiratory Rates Normal Heart Rates* (beats/min) (breaths/min) Age Awake Rate Sleeping Rate | Age Rate Neonate 100-205 90-160 Infant 30-53 Infant 100-180 90-160 Toddler 22-37 Toddler 98-140 80-120 Preschooler 20-28 Preschooler 80-120 65-100 School-aged child 18-25 School-aged child 75-118 58-90 Adolescent 12-20 Adolescent 60-100 50-90 Normal Blood Pressures Systolic Diastolic Mean Arterial Age Pressure Pressure Pressure (mm Hg)t (mm Hg)t (mm Hg)! Birth (12 h, <1000 g) 39-59 16-36 28-428 Birth (12 h, 3 kg) 60-76 31-45 48-57 Neonate (96 h) 67-84 35-53 45-60 Infant (1-12 mo) 72-104 37-56 50-62 Toddler (1-2 y) 86-106 42-63 49-62 Preschooler (3-5 y) 89-112 46-72 58-69 School-aged child (6-7 y) 97-115 $7-76 66-72 Preadolescent (10-12 y) 102-120 61-80 71-79 Adolescent (12-15 y) 110-131 64-83 73-84 “Always consider the patient's normal range and clinical condition. Heart rate will normally increase with fever or stress. Systolic and diastolic blood pressure ranges assume 50th percentile for height for children 1 year and older. *Mean arterial pressures (diastolic pressure + difference between systolic and diastolic pressure/3)) for 1 year and older, assuming 50th percentile for height. Approximately equal to postconception age in weeks (may add 5 mm Ha). Reproduced from Hazinski MF. Children are different. In: Hazinski MF, ed. Nursing Care of the Critically ll Chitd. rd ed. St Louis, MO: Mosby; 2013:1-18, copyright Elsevier. Data from Gemelli M, Manganaro R, Mami C, De Luca F. Longitudinal study of blood pressure during the 1st year of life. Eur J Pediatr. 1990;1495):318-320; ‘Versmold HT, Kitterman JA, Phibbs RH, Gregory GA, Tooley WH. Aortic blood pressure during the first 12 hours of life in infants with birth weight 610 to 4,220 grams. Pediatrics. 1981;67(5).607-613; Haque IU, Zaritsky AL, Analysis af the evidence for the lower limit of systolic and mean arterial pressure in children. Peaiatr Crit Care (Med. 2007;8(2):138-144: and National High Blood Pressure Education Program Working Group on High Blood Pressure in Children and Adolescents. The Fourth Report on the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents. Bethesda, MD: National Heart, Lung, and Blood Institute; 2005, NIH publication 05-5267. 15-1046 10/16 | © 2016 American Heart Association ISBN 978-1-61669-560-6 Printed in the USA,uossiuued yh pojuudey ‘Auediiog pue Losuniaig ‘UO}Ieg © pur Asaynog ‘ou) suBig (e3iA 2002 1UBUAdOD “| ‘ouIYSUjOoUIT ‘oul SeL|SNpU! eoIPeyy BUOASUUY fq pernqiAsiG ‘ede, ADLAB IEW IUREIPEY W,mojesoig Woy pardepy ‘(Pied sug 40 @pIS 9840/01 Buy LO 9zIg eqny, [eeYoeACPUT BuyoWNSy eas) pasn eq Ae seqny Peynaun 40 Paynd jedsoy ayy UI ‘SOU/EPIND WHY 010Z 10d, PAIS! 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PIMOAUER — PINOAUEH om so D uoneyosnsey) a J a8 [atPediatric Cardiac Arrest Algorithm—2015 Update Start CPR * Give oxygen Asystole/PEA CPR 2 min * IO/IV access CPR 2 min * IO/IV access * Epinephrine every 3-5 min * Consider advanced airway CPR 2 min * Epinephrine every 3-5 min * Consider advanced airway CPR 2 min ° Treat reversible causes CPR 2 min * Amiodarone or lidocaine * Treat reversible causes * Asystole/PEA > 10 or 11 * Organized rhythm > check pulse * Pulse present (ROSC) + post—cardiac arrest careDoses/Details for the Pediatric Cardiac Arrest Algorithm CPR Quality * Push hard (2% of anteroposterior diameter of chest) and fast (400-120/min) and allow complete chest recoil. Minimize interruptions in compressions. * Avoid excessive ventilation. Rotate compressor every 2 minutes, or sooner if fatigued. * If no advanced airway, 15:2 compression-ventilation ratio. Advanced Airway * Endotracheal intubation or supraglottic advanced alrway * Waveform capnography or capnometry to confirm and monitor ET tube placement * Once advanced airway in place, give 1 breath every 6 seconds (10 breaths/min) with continuous chest compressions Return of Spontaneous Circulation (ROSC) ¢ Pulse and blood pressure * Spontaneous arterial pressure waves with intra-arterial monitoring Shock Energy for Defibrillation First shock 2 J/kg, second shock 4 J/kg, subsequent shocks 24 J/kg, maximum 10 J/kg or adult dose Reversible Causes Drug Therapy Epinephrine I0/IV dose: Hypovolemia Hypoxia 0.01 mg/kg (0.1 mL/kg of the Hydrogen ion (acidosis) 0.1mg/mL concentration). Repeat Hypoglycemia every 3-5 minutes. If no |O/IV Hypo-/hyperkalemia access, may give endotracheal Hypothermia dose: 0.1 mg/kg (0.1 mL/kg of the 1 mg/mL concentration). * Amiodarone 10/IV dose: 5 mg/kg bolus during cardiac arrest. May repeat up to 2 times for refractory VF/pulseless VT. Lidocaine IO/IV dose: Initial: 1 mg/kg loading dose. Maintenance: 20-50 mcg/kg per minute infusion (repeat bolus dose if infusion initiated >15 minutes after initial bolus therapy). Tension pneumothorax Tamponade, cardiac Toxins Thrombosis, pulmonary Thrombosis, coronary eo eererre ce ee Estimating Endotracheal Tube Size The formula for estimation of proper endotracheal tube size (internal diameter [i.d.]) for children 2 to 10 years of age, based on the child’s age: Uncuffed endotracheal tube size (mm i.d.) = (age in years/4) + 4 The formula for estimation of a cuffed endotracheal tube size is as follows: Cuffed endotracheal tube size (mm i.d.) = (age in years/4) + 3.5 Typical cuffed inflation pressure should be <20 to 25 cm H,O.PALS Systematic Approach Algorithm Initial impression (appearance, breathing, circulation) Is child unresponsive or is immediate intervention needed? a | Shout for help. | Activate emergency response plan (as appropriate for setting). No breathi or only gasping, no pulse Does child have severe compromise of No breathing, but pulse present Open and maintain airway. Begin ventilation. | Provide oxygen when available. | Attach monitor, pulse oximeter. { Support airway, ventilation, | | and perfusion. Provide oxygen as needed. Attach monitor, pulse oximeter. sa a ete Is pulse <60/min with poor perfusion despite If at any time you identify cardiac arrest Evaluate * Primary assessment * Secondary assessment © Diagnostic assessments Start CPR (C-A-B). Intervene “és Pediatric Cardiac Arrest Algorithm. After ROSC, provide post-cardiac arrest care. Begin | evaluate-identify-intervene sequence. eee DPediatric Bradycardia With a Pulse and Poor Perfusion Algorithm Identify and treat underlying cause * Maintain patent airway; assist breathing as necessary * Oxygen * Cardiac monitor to identify rhythm; monitor blood pressure and oximetry | * IO/IV access | + 12-Lead ECG if available; don't delay therapy Cardiopulmonary compromise? ° Hypotension © Acutely altered mental No CPR if HR <60/min with poor perfusion despite nation and ventilation © Support ABCs | © Give oxygen Doses/Details | ies: Observe Epinephrine l0/IV | * Consider expert dose: 0.01 mg/k: consultation MT REA ore. — (0.1 mL/kg of the ———————— 0.1 mg/mL concentra- - tion). Repeat every | | 3-5 minutes. If IO/IV | access not available but endotracheal (ET) tube in place, may give ET dose: © Epinephrine * Atropine for increased vagal tone or primary AV block * Gonsider transthoracic pacing/ transvenous pacing | | * Treat underlying causes | 0.1 mg/kg (0.1 mL/kg of the 1 mg/mL concentration). Atropine 10/IV dose: 0.02 mg/kg. May If pulseless arrest repeat once. Minimum develops, go to Cardiac dose 0.1 mg and Arrest Algorithm maximum single dose 0.5 mg.PALS Management of Shock After ROSC Algorithm Optimize Ventilation and Oxygenation © Titrate Fi, to maintain oxyhemoglobin saturation 94%-99% (or as appropriate to the patient’s condition); if possible, wean Fld, if saturation is 100%. © Consider advanced airway placement and waveform capnography. © If possible, target a PCO, that is appropriate for the patient’s condition and limit exposure to severe hypercapnia or hypocapnia. "Assess for and *Possible Treat Persistent Contributing Factors | Shock Hypovolemia * Identify and treat Hypoxia contributing factors* Hydrogen ion (acidosis) * Consider 20 mL/kg Hypoglycemia IVAO boluses of Hypo-/hyperkalemia isotonic crystalloid. Hypothermia Consider smaller boluses (eg, 10 mL/kg) if poor cardiac function suspected. * Considertheneed | for inotropic and/or | vasopressor Support — for fluid-refractory shock. Tension pneumothorax Tamponade, cardiac Toxins Thrombosis, pulmonary Thrombosis, coronary Trauma Hypotensive Shock * Epinephrine * Dopamine * Norepinephrine | Normotensive Shock * Dobutamine * Dopamine * Epinephrine * Milrinone Sint eesti * Monitor for and treat agitation and seizures. * Monitor for and treat hypoglycemia. * Assess blood gas, serum electrolytes, and calcium. If patient remains comatose after resuscitation from cardiac arrest, maintain targeted temperature management, including aggressive treatment of fever. © Consider consultation and patient transport to tertiary care center, | Estimation of Maintenance Fluid Requirements © Infants <10 kg: 4 mL/kg per hour Example: For an 8-kg infant, estimated maintenance fluid rate = 4mL/kg per hour x 8 kg = 82 mL per hour Children 10-20 kg: 40 mL per hour + 2 mL/kg per hour for each kg above 10 kg Example: For a 15-kg child, estimated maintenance fluid rate 40 mL per hour + (2 mL/kg per hour x 5 kg) = 50 mL per hour * Children >20 kg: 60 mL per hour + 1 mL/kg per hour for each kg above 20 kg Example: For a 28-kg child, estimated maintenance fluid rate 60 mL per hour + (1 mL/kg per hour x 8 kg) =68 mL per hour After initial stabilization, adjust the rate and composition of intravenous fluids based on the patient's clinical condition and state of hydration. In general, provide a continu- ous infusion of a dextrose- containing solution for infants. Avoid hypotonic solutions in Critically ill children; for most Patients, use isotonic fiuid such as normal saline (0.9% NaCl) or lactated Ringer’s solution with or without dextrose, based on the child’s clinical status.ete aca temo cerlee lt Mu ot ey) Elite ella cam Vel alii bole e ley Identity and treat underlying cause * Maintain patent airway; assist breathing as Meee] necessary er elle * Oxygen * Cardiac monitor to identify rhythm; monitor blood | Begin with 0.5- pressure and oximetry 1 1 J/kg; if not * IO/V access i effective, * 12-Lead ECG jf available; don’t delay therapy ! increase to 2 J/kg. Sedate Narrow Wide Ineetied; but don’t delay {<0.09 sec) a {>0.09 sec) Catiovenci. QRS duration Evaluate rhythm . with 12-lead ECG Adenosine ‘or monitor 1O/IV dose: saisbpaas set First dose: 0.1 mg/kg rapid — . os bolus (maximum: Probable Probable i Possible 6 mg). sinus supraventricular ventricular Second dose: tachycardia tachycardia ——_|_ tachycardia 0.2 mg/kg rapid | © Compatible * Compatible a es bolus (maximum | history history (vague, | re cose consistent with nonspecific); i ma). | known cause history of abrupt | pemodarons | i IOV dose: * P waves rate changes i 5 mg/kg over present/normal * P waves absent/ 20-80 minutes * Variable R-R; abnormal or constant PR © HRnotvariable ; Procainamide © Infants: Infants: rate | IOV dose: rate usually usually 2220/min Cardiopulmonary 15 mg/kg over <220/min * Children: rate 1 compromise? 30-60 minutes + usually2180/min ./ * Hypotension Do not routinely * Children; rate ; * Acutely altered administer usually <180/min : mental status amiodarone and © y y procainamide | together. G eeath for ] Consider | | ( ; i } | | Synchronized | | Consider | | and vagal cardioversion || adenosine | | treat cause maneuvers — X J if rhythm regular | (No delays) | and QRS monomorphic ¢ ae C >) | © If |O/V access present, give adenosine | Expert | or | consultation | * If IO/V access not available, or if adenosine advised ineffective, synchronized cardioversion * Amiodarone * Procainamide ceeete aca temo cerlee lt Mu ot ey) Elite ella cam Vel alii bole e ley Identity and treat underlying cause * Maintain patent airway; assist breathing as Meee] necessary er elle * Oxygen * Cardiac monitor to identify rhythm; monitor blood | Begin with 0.5- pressure and oximetry 1 1 J/kg; if not * IO/V access i effective, * 12-Lead ECG jf available; don’t delay therapy ! increase to 2 J/kg. Sedate Narrow Wide Ineetied; but don’t delay {<0.09 sec) a {>0.09 sec) Catiovenci. QRS duration Evaluate rhythm . with 12-lead ECG Adenosine ‘or monitor 1O/IV dose: saisbpaas set First dose: 0.1 mg/kg rapid — . os bolus (maximum: Probable Probable i Possible 6 mg). sinus supraventricular ventricular Second dose: tachycardia tachycardia ——_|_ tachycardia 0.2 mg/kg rapid | © Compatible * Compatible a es bolus (maximum | history history (vague, | re cose consistent with nonspecific); i ma). | known cause history of abrupt | pemodarons | i IOV dose: * P waves rate changes i 5 mg/kg over present/normal * P waves absent/ 20-80 minutes * Variable R-R; abnormal or constant PR © HRnotvariable ; Procainamide © Infants: Infants: rate | IOV dose: rate usually usually 2220/min Cardiopulmonary 15 mg/kg over <220/min * Children: rate 1 compromise? 30-60 minutes + usually2180/min ./ * Hypotension Do not routinely * Children; rate ; * Acutely altered administer usually <180/min : mental status amiodarone and © y y procainamide | together. G eeath for ] Consider | | ( ; i } | | Synchronized | | Consider | | and vagal cardioversion || adenosine | | treat cause maneuvers — X J if rhythm regular | (No delays) | and QRS monomorphic ¢ ae C >) | © If |O/V access present, give adenosine | Expert | or | consultation | * If IO/V access not available, or if adenosine advised ineffective, synchronized cardioversion * Amiodarone * Procainamide ceePediatric Septic Shock Algorithm Bere we le eee) Initial stabilization rc Identity Signs of Septic Shook (as below or per protocol} * Altered mental status (irtabilty or decreased level of consciousness) Altered heart rate (tachycardia or, less commonly, bradycardia) * Altered temperature {fever or hypothermia) * Altered perfusion (prolonged or “flash” capillary ref; cool or vory warm extremities; plethorie appearance, mottled color or pallor possible ecchymosis or purpura; decreased urine output) ‘+ Hypotension: May or may not be present | Immediate (10-15 min) Initial Stabilization Monitor and suppor airway, breathing, and circulation | + Monitor heart rae, blood pressure, and pulse oximetry | + Esicblsh vasculer access (Vor 10}; draw blood for culture and |” adaitional tasoratory studios, including glucose and eacum—do rot | Gelay antibiotic ofc therapy | | | + Antibiotics: Give broad-spectrum antibiotics + Fluid boluses: Give 20 m./g isotonic crystaloid boluses (10 mLikg, for neonates and those with pre-existing cardiovascular compromise}. ‘Assess carefuly after each bolus. Repeat as needed to treat shock. Stop ffrales, respiratory distress, or hepatomenaly develops, | + Give antipyretics it needed | Goals of therapy: Improved mental status, normalization of heart | tate and temperature, adecuste eystolic ard diastolic blood pressure | _ Improved perfusion (see box above) First hour’ Consider critical care consultation ‘ Obtain expert/enitical care consultation * Initiate and titrate vasoactive drugs: } = Cold extremities, delayed capillary refil, and/or low blood pressure: Epinephrine (use dopamine if epinephrine is not availabe) ~ Warm extremities, “flash” capillary refil, and/or low (typically diastolic) blood pressure: Norepinephrine (Use higher dose of dopamine if norepinephrine is not available) ‘Therapies intendad forthe critical care environment and expertise {+ Establish contral venous and intra-arterial pressure monitoring * Continue epinephrine/norepinephrine (as above) and bolus fluid therapy as needed to treat shock * Verity adequate airway, oxygenation, and ventlation * Evaluate cortisol if at risk for relative adrenal inaufficiency; consider atross dose hydrocortisone Critical care goals of therapy: Scv0, >70%, adequate BR normalized HR, adequate cardiac output/index and organ perfusion y ovo, <70% Sev0,270% Scv0,270% With poor With poor pertusion Signs of perfusion and ‘and warm shock cold extremities extremities despite resolved despite | norepinephrine epinephrine | ‘administration ‘administration t Y Y | eee) 9 sees ee | eee) oe ee se | ae + Support organ function Goals of care: Improved Sevo,, normalized HF and BP, Adequate cardiac outpuvindox ana organ perfusion normalized HR and BP adequate cardiac output/index and ‘organ perfusionDrugs Used in PALS Drugs Used in PALS (continued) cone et W mthrs r w om 02 aa 0 e an mote Orton 388 etm ont saa Seeiarante en Anal ht wes ce pea Tera | Rt acer PARLE ees ei eaten ‘Sage tee ab vetoncter lassen Sige ou ee EEE” [27S sone ueinanaat nse astom «Nw 05 tot ve anon oh a : : Fea | Be re izes | ann or woes one PS Cassone m9 mothe Sno ee ee ean aus i * pelea SecRe ate SPREE ae rena ane | iets SS So tine oa aE a ‘Atropine suttote | Bradyeardia (symptomatic) = nae neces ane nainsninan | [ame | Sarasttaten inert tment aes omecer {62 mot VAG fax snc dour my won don * a sie ofS sora fas ance _ Suissa" ; wag en ee eaten geese ue ama cma om | SE SaaS aN a PATRTR CSE MSTS eT anette som mey | [omni | Hae renga caches aa ML trict a eat ee newsvine | | [TOR en itn rg BT patente seen aA a ns ty0250 SEE Resort merits peropanas Sorina oe = _ Seciros {trated nares sovoah arouse RTE ent earner ra Sas, | igen nami reper a ent ore Wraith ete eg ioe | Memes Neng uN rs ea OMT eel et and nc Saas Ser wey Posen hones arta PEisnironaenrin ria eaSteS gra ai 5 : * Tashan in een er Cie LW 5 to 10 mig ++ Initlate at 0.25 to 0.6 megikg per minute IVA infusion; titrate by + xa per i a S82 GAMO DAW 215 SNe UNS 2 ‘minute q 15 to 20 miwtes as tolerated, Typical dose range 1 to 5 megikg per Desa [Fe ir cere oes eee aoe [SPO RRUE SRE wee ee « Rada SP its nn ut oan rn ‘Dopamine | Cariogonte shook, dstbuatve shock ee SEEREIS EST amnesia: | ira Saco os cee RL INR ‘cna er rr ira) oe sre we Migeaaw Meters SR wen 0 a3 rian Tosa | gees ey Sit ck 8 ocr (mocangl one m0) exc, BF 'a2 mega et mate No sao tee to ees tect ESSEC om nontsmrennteTestsniue | sctetnsr reat ieee "tb WA load ove S00 89 minus (ont wee atin wth amidaon Pe emma nce em SSE IO Be ~ spn | Dither wn en as Pecos rage ter eg 50.9 ier asenecorossma| [EBSEI™ |Posaeratsngoe ease tn ta baron SeftetgBBSLSS 0S Prom scien aa smn a rman — a liaaumeceees Sea esi a gh a Sage thet agp onersey0 4 St = i permeate Se es ea re vert mares EES BRIN en angina pet dt SERS eee Te nen alias nt acly anand aoeaios mcs aro SoA — Terbutaline | ‘Asthma (status asthmatious), hyperkalemia © COLgO 01 ottg oe gf. comer) aay 1 nen Dito fo mopig pr mate NO nk consider 10 mcg MO fad ovr areal ee 8 cers msec ser 2a nm Na man «Eee cement nto wo nor i one pacescrnt ter ten oa SOLES A tnsaomerimurea ae a Coan fo 0.00 una po mints 2 to 2 miles pet mint) contnuous non