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NRP/PALSUpdate:SavingTinyLivesin2017

AndreJakubow,MD,CCFP(FPA)November2017

TheBeautyofNRP&PALS•  Awell-runcodeisaworkofart.

•  SimpleintervenAonssavelives.KidsrespondgraAfyinglyfasttotherightintervenAons(e.g.effecAvePPVinNRP).

•  Andyet… skillsdecayfastandImeisoftheessence:manytasks,allatonce…–  SystemaIcApproachhelps–  TeamDynamics/HumanFactors/CRMhelp

ObjecIves:

1.   Refresh&rehearsestepstotakewhenresuscitaAngcriAcallyillnewborns(NRP)andchildren(PALS)

2.  DescribethemainchangestoNRPandPALSguidelinesin2015updatesandmorerecentfindings

3.  StrengthengoodpracAcesinteamdynamics&“crewresourcemanagement”toopImizeoutcomes

4.   ReviewfrequenterrorsNRPersandPALSiesmakeDoesNOTreplaceanofficialcourse;opinionsmyown;evidencemostlylow-quality,butwillbemenAoned

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Method:ResuscitaIonGame

•  We’regoingtoplayagame.•  Step-by-step“walkthrough”,imaginary‘codes’:1NRP,1PALS

•  Ateachstep:“OneCueèXResponses”•  Giveyourbestguess,shortanswer(afewwords)•  ONEanswerperperson.Allowedto“pass”•  Quickanswersplease!KeepItMoving!Mistakesareexpected–&partofthefun.

IntroducAons

•  CCFP(McGill),FP-Anesthesia(U.ofT.)•  PALSInstructor(HSFC)•  NRPInstructor(CPS)•  ProfessionalInterests:familymedicine;medicaleducaAon;anesthesia;simulaAon;crisisresourcemgmt

•  ConflictsofInterest:none

Warm-upRound:“ACodeBlue/Pink/Trauma/OutdoorEmergencyisunfolding.Whatareyourbasicstepstoprepare?”(3

keyresponses)

1.   SceneSafety:Fire/wire/gas/glass/guns/thugs/drugs2.   TeamBriefing:TakeLead!AssignRoles!GetHelp!

“I’lltaketheLeadrole.“Jeff-canyoubetheAirwayperson,startcheckingpulse&breathing;”“Sandra-canyouputontheMonitorsnow;”“Laura-pleasestartanIVandgetMedsready…”

3.   AssignEquipmentCheck:e.g.STATICS-MIMM

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SCENARIO1:NRP

Cue1:YouArrive@Delivery.“BabyComingSoon,YouReady?”(4keyresponses)

1.   (SceneSafety)2.   TeamBriefing:–  TakeLeadRole!Assign

TeamRoles!3.   EquipmentCheck:

“STATICS-MIMM+4”

4.   AskFOURpre-birthquesIons:– MulA-baby?–  GestaAonalAge?–  RiskFactors?– Meconium?

Cue2:Birth(!)(3keyresponses)

•  Ask3post-birthquesAons:–  “Term?”(i.e.“isGAapprox.correct?”)–  “Tone?”–  “BreathingorCrying?”

•  IFall“YES”es:–  …relax…rouAnecare

•  IFany“NO”s:–  BRINGTOWARMERand…

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Cue3:BabyHitsWarmer(4)•  PosiAonforopenA/W≈

Sniffing(≈“shldrroll”)•  “ClearAirwayIfNeeded”•  “Dry-SAmulate-Remove

WetTowels”

(Hiddenstep:)u AskMonitorspersonto

assessHR&BS(A/WpersonmaybebusysucAoning)

AWordOnMeconium

•  FORMERLY,NRPadvisedthatALL“non-vigorous”babieswithmeconiumbeintubatedandsucAonedthroughtheETTpriortogivingPPV.

•  7thediAonNRPrecommendsnotrouInelyintubaAngandsucAoningsuchbabies

•  BUTit’ssAllanopAon•  SHOULDbeconsidered(attheSofMRSOPA)iftroublevenAlaAng

Cue4:“HR<100”{OR}respsineffecIve(1keyresponse+3secondary)

•  STARTPPVwithroomair(21-30%if<35wkGA)

•  WheneverPPVisstarted:–  think“Maskonface?Satprobe

onRthand;{ANDECGleadsonchestagoodideatoo}”

Hiddenstephere:•  ImmediatelyAskMonitorsPerson

toauscultatetoconfirmwhetherPPVisworking:

•  *HRrisesufficienttoprovisionallyprovegoodPPV;

•  otherreassuringsignsshouldbesought,e.g.audibleBS,visiblechestrise,(ETCO2)

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Cue5:PPVstarted,butHRnotrising<15sec.Whattodo?(1)

•  Theproblemisalways*lackofvenAlaAon.

•  SoassumeyourvenIlaIonisfaultyfirst.OnlybreakthatassumpAonw/greatcauAon,andif:–  definiteCHESTRISE–  definiteBREATHSOUNDSbilat–  definite+ETCO2(rare

excepAons)*

DON’TBLAMEBABY.

BlameYOURfaultyPPV.

DOMRSOPA.

*ExcepAonsSOrarethatyouDONOTworryaboutthemforthefirst15secondsofPPV.DoMRSOPA!

ComputerHelpDeskTechnicians

List“MRSOPA”steps.(6)

•  MaskSeal•  ReposiIon(…theairway…≈shoulderroll)

•  SucIon•  OpentheMouth

•  Pressureincrease(to30cmH2O,cauAouslyto≤40)•  Alternateairway(ETTrecommended,orLMA)

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MRSOPA:“AlternaIveAirway”

…@“A”ofMRSOPA,youdecidetointubate…

Cue5B:“MRSOPA”complete,butnoHRrise<15sec.Whattodo?

GloocimpersonaIonKovacsetal.,CanJAnesth(2017)64:320

•  R/OesophagealintubaAon(sustained+ETCO2bestr/o;alsochestrise,brsnds,mist)

•  R/OendobronchialintubaAon(tubeslippedintoofar?)–checkETTdepth

•  ConsiderLMA•  Asalways:first&only&

constantly-to-be-repeatedquesAonisareyouSUREyou’revenAlaAngthelungs:ETCO2?Chestrise?Breathsounds?

Cue5B:“MRSOPA”complete,butnoHRrise<15sec.Whattodo?

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Cue6:definitely-goodPPVx30s,butHRstays<60(1response,+5linkedacIons)

•  STARTChestCompressn’s

•  WheneverCC’sstarted:“Thumbsonthechest=>

1.  (TUBEintheTRACHEA,)2.   100%O2onBLENDER,3.   ECGleadsonCHEST…AndprobablyagoodAmeto

4.  Get‘M/M’starIngaUVC5.   CallforMOREHELP/

NEONATOLOGY*CRMpoint:Tigercountryahead;anAcipaAng;gevngslowtasksstartedearly,offloadingfuture

Cue7:DefinitelygoodPPV&CCs.WhentorecheckHR?SIll<60…whattodo?(3)

Epinephrine;recallthisisonlyindicatedifHRremains<60arer:•  Atleast30secEFFECTIVEPPV

(w/chestmvt,±ETCO2)•  FOLLOWEDBY

addnl60secofCC’sw/100%O2Dose:0.1ml/kgof0.1mg/mlepinephrine(≈usualdoseis≈0.3ml),viaUVC/IV/IOInthesesituaAons,•  Considerhypovolemia•  ConsiderPTX

•  Re-evalwhetherETTreallywell-placed/ETCO2…

Cue8:Baby’sHRimproves,theystarttocry.Yousavedthem,congrats…anyfinalacIons?(2)

Postresusc.CareTeamdebriefingTalkwithparentsGiveselfhigh-five

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NRP:Summary/7thedΔs•  SceneSafety•  TakeLeadRole!AssignTeamRoles!(=TeamBriefing)•  EquipmentCheck(Isuggest“STATICS-MIMM+4”)•  4pre-birthQ’s•  3post-birthQ’s•  IniAalSteps(posiAon,clearairwayPRN,dry,sAmulate);assessHR/BS;

meconiumsucAonnotrouAne,butOKPRN.IfHR<100orapnea/gasping:•  PPV:21%O2,~30%for<35wGA

Maskonfaceèsatprobehand&ECG.Immed.ChestRise/HR/BScheck.•  MRSOPAimmediately(<15sec)ifPPVineffecAve•  ChestCompressions(if30seceffecAvePPV&sAll<60):thumbsonchest

èO2to100%-Tubeintrachea– ECGonchest– GetaUVCrolling(IOifunable)– Callformore/neonatologyhelp

•  Epinephrine;crystalloid,blood;explicitlyconsiderPTX/hypovol.

Barriers&SoluAons

•  Barriers:Cost(ECGmonitors,O2blenders),ChallengingSkills,InfrequentExposure

•  SoluIons:Budget,regularsimulaAon(esp.UVC,ETT/LMA);supportforrecurrenttraining;collegialneighbourhoodanestheAstsinterprofessional/regional/prov/natsupport

MOVINGONFROMBABIESTOKIDS…

Imagecredit:h~ps://www.highlights.com/parents/arAcles/helping-babies-deal-transiAons

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ALovelyStrollThroughtheMall

(InterruptedbyacommoAon)

•  Asmallcrowdmillingaround…

Cue1:CommoIon,?UnconsciousChild(3Responses)

•  SceneSafety!•  TeamBriefing:Take

Charge!AssignTeamRoles!(?Parents?)

•  (EquipmentCheck!)=gettheequipmentmovingtowardyou

•  CheckforResponsiveness

•  SimultaneousPulse&BreathingCheck

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Cue2A:Unresponsive,NOBrthg,NOPulse(2)•  Call9-1-1,SendforAED•  StartCPRasC-A-B:Compressions,thenVenAlaAons;“IrememberBLS!”

•  RaIo: “30:2foreveryone,except…” two-rescuerchild&infant,inwh.case15:2

•  LEAVEtoPhonefirst?orCPR-2-mins-Then-Leave-and-Phone?

–  “LEAVEtofindphonefirstforeveryone,except…”One-Rescuer,Child&Infant,Unwitnessed:DO2cycles’CPRbeforeleavingtophone.KidsburnO2fast;UNWITNESSEDimpliespossibleprolongedhypoxia.

•  Depth: 1/3chestwalldiameter(“4cminfants,5cmchild, 5-6cmadults”seemssillytome)

•  Rate: 100~120/min•  Other: MinimizeInterrupAons;FullChestRecoil

–  Newin2016:“considerafeedbackdevice”

Cue2B:Unresponsive,breathingNO,pulseYES(afreebie)

•  RescueBreathing–  (1breathq3~5sec)=12~20/min

Cue2C:Responsive,butpoorlyso,andobviouslyhe’sbreathingandhasapulsegiventhatanyresponsivenesswouldbe

impossiblewithoutthese(1response)

•  PALSPrimary(1°)Survey– A– B– C– D– E

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HowTo:Evaluate-IdenAfy-Intervene

•  ConAnuouscycle•  DoingPrimarySurvey+/-SecondarySurv.+/-Dxtests=“Evaluate”

PALS1°Survey“A”(4responses)

•  Look:chest/abdomenmovement

•  Listen:Stridor,Gurgling•  Feel:ifnecessary•  Fixissuesfound– a/wpatencywillbemaintainableSpontaneouslyorw/Simple(jawthrust,sucAon,Heimlich,OPA/NPA),orw/Advanced(BMV,CPAP,ETT/LMA/cricothyrotomy)

PALS1°Survey“B”(5responses)

•  Rate/Pazern•  Volume:chestexpansion

•  Effort(WorkOfBreathing):retracAons,etc.

•  BreathSounds(byauscultaAon)

•  O2Sat

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PALS1°Survey“C”(5responses)

•  HeartRate&Rhythm•  BP

•  CapRefill•  SkinTemperature•  PeriphPulses

PALS1°Survey“D”(3responses)

•  AVPUorGCS•  Pupils•  Glucose

PALS1°Survey“E”(2responses)

•  Expose/Examine/ExtremiIes:– Rash-purpura/Trauma/Bruising

•  CoreTemperature

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Yourfindingsinthiskid:

•  PALS1°Survey,“Evaluate”:– A:stridor/snoring,AWneedingjawthrusttomaintain;?puffyface

– B:RR35,shallowVt,diffusewheezing,O2satunk.– C:sweatyextremiAes,shock,caprefill4sec;PPweak– D:anxious,responsivetoPain,pupilsOK,Gluc.unk– E:urAcarialrash,tempunknown

•  Whatcanyou“IdenAfy”theproblemas?

?

Imageavailableat:h~p://www.bbc.com/news/health-25950422

Cue3:1°SurveyDone,NowWhat?

•  ConsiderInterven-ing

•  OrfurtherEvaluat-ion,ifsAlluncertain

•  Eitherway,a“SUMMARIZING”statementishelpfulatthisjuncture(CRM!)

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Evaluate-IdenAfy-Intervene•  StateType&Severity•  Type:

–  “Respiratory”/“Circulatory”/“Both”•  UpperAW•  LowerAW•  LungTissue•  DisorderedControl

–  Shock:Cardiogen./Hypovol./ObstrucAve/DistribuAve

•  Severity:–  Resp.Distressvs.Resp.Failure–  Shock:Compensatedvs.Hypotensive

CRMpoint:SUMMARIZING:“OKfolks,thislookslikesomekindofshocktome,becauseofhis{slowcaprefillandcoldextremiAesw/normalBP},andwhat‘Type’ofshock,I’mnotsureofyet…”

EffecAveTeamDynamics/CRM

•  SummarizingStatements(SHAREyourmentalmodel!)

•  ClearRoles&ResponsibiliAes•  ClearMessages•  Closed-LoopCommunicaAon•  MutualRespect•  ConstrucAveIntervenAon•  KnowingOne’sLimitaAons

h~p://www.royalcollege.ca/rcsite/ppi/educaAonal-resources-e

Cue3:What’sPALS2°Survey? (2)

•  SAMPLEHistory,plus•  Head-to-toeExam

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ListSAMPLEhx?(6)

•  Signs&Symptoms•  Allergies•  Meds•  PastMedHistory•  LastMeal(“Mostrecentmeal”)•  Events

•  Thendo“Head-to-toeexam”tofinish2°srvy

Intervene:Epinephrine,10mcg/kg,IM

Cue4:2°SurveyFinished…(1response)

•  ConsiderDiagnosIcTests

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Cue5:DiagnosIcTestsOrdered…(1response)

•  Re-“Evaluate”ABCDE•  Summarize

•  Post-Resusc.Care•  Consultcolleagues•  DiscusswithpaAent/parents

•  TeamDebriefing…

TheKidSurvives!…Congrats

PALS:OverallAlgorithm•  IniIalImpression/Pulse&Brthgsimultaneously;if+:•  1°Survey:–  A:look/listen/feel/fix–  B:rate/volume/effort/auscultate/O2sat–  C:HR/BP/CapRefill/SkinTemp/PeriphPulses–  D:Pupils,GCS/AVPU,Glucose–  E:Expose/Examine/ExtremiAes

•  2°Survey:–  SAMPLEhistory–  Head-to-toeexam

•  DiagnosIcTests

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Misc.Changes:2015PALS•  AtropinepremedicaIon:notrecommendedforemergency

intubaAon(conflicAngevid)–sIllhaveitreadyjustincase

•  FluidresuscitaIoninsepIcshock:DOuseiniAal20ml/kgcrystalloidforkidswithshock,butnotfor‘severefebrileillnesswithoutshock’.Low-resourcesevngs(i.e.non-ICUsevngs)shouldprobablyavoidexcessivefluids–basedonAfricanstudy-kidswithdengue/malaria

•  TargetedTemperatureManagement:pedsout-of-hospitalcardiacarrestwhoareunresponsivea�erROSC,either32-34or36-37.5CelsiusareopAons;probablymostimportant(&low-effort)toavoidhypERthermia(THAPCA-in/out-of-hospitaltrials)

QuesAons?

•  ?

Recap•  PrinciplesofNRP&PALSsimilar:–  Arrestscausedbyresporshock>>cardiovascularcauses–  Pre-Arrest(compensated/‘distress’stage)>>arrest(hypotensive/decompensated/organ-‘failure’stage)

–  IdenAfy&Fix“rapidly-fatal”threatsfirst–  VenIlaIon/OxygenaIonprovide+++benefit;circulatorysupport(fluids/inotropes)in2ndplace

–  Capnography(ETCO2)o�enagoodidea–  BLS/QualityofCPR/EarlyDefibmoreimportantthanmeds(e.g.epi);find&treatcausewithspecificRx’s•  E.g.Hypovolemia?Fluids.Anaphylaxis?Epinephrine.Sepsis?AnIbioIcs&sourcecontrol…

•  SystemaIcAprch,OrganizedTeamDynamics/CRM

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ThankYou

•  ThankyouforyourcommitmenttoexcellentcareofcriAcallyillnewbornsandchildren

•  THEEND…nowsomefuntopicsforfurtherdiscussion…

OurKidsDependOnYourSkills

CommonMistakesPALS/NRPersMake1.   TheBradycardiaBlunder2.   SystemaIcAssessmentSlipups3.   RealLifeHesitaIon4.   EsophagealIntubaIonsUnrecognized5.   AlgorithmConfusion6.   EquipmentCheckFoibles7.   CommunicaIonBreakdowns

CommonMistake1:BradycardiaBlunder

•  “HR<60withpoorperfusion.ThatmeansIneedtostartCC’sSTAT!”Right?

•  FALSE.

•  EffecPvePPV/O2/CO2mustbeestablished‘x30sec’beforeCCsbecomeanopAon.*commonthread(NRP&PALS)!

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PALS2015BradycardiaAlgorithm

CommonMistake2:SystemaAcAssessmentSlipups

•  “not-so-systemaAc”/“JumpingtoCnclsns”•  FixaPonerrors:“Thismustbesepsis!”

•  Remedy:Askyourself,“Whatelsecouldthisbe?”•  UsewriYenguide/checklisttohelpyounotskipsteps

CommonMistake3:RealLifeHesitaAon

•  “Idon’twanttoputa*tube*inthisbaby!”•  “Anumbilicalveincatheter?ThatseemsdrasPc…”•  Unexpectedevents,‘formerly’-healthybabies

•  Remedy:ExpectsomeAmestohavetoprovideinvasivetherapiestobabiesyoudidn’tthinkweresick,ifnowtheyaresick

•  IfETT/LMAindicated,be~ertouseitthannot•  UVC(placedcorrectly)isafew-cm-lengthcatheterinaneasilyaccessiblevein,reliable,relaAvelysafe,o�enfasterthanperiphIVandsaferthanIO

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CommonMistake4:EsophagealIntubaAonsUnrecognized

•  EvenexperiencedMDsputETTsdowntheesophagus•  That’sforgivable•  What’snotforgivableisnotrecognizingitimmediately•  EvenlessforgivableisconAnuingtheresuscwith‘falsesenseof

security’that“thekid’sbeenintubated,soA/BareOK”whenthey’renot

•  Remedy:UseALLyourclues(especially+ETCO2);ConsidertheETTanuntrustworthy,slipperycreaturethatsomeAmesisin,someAmesslipsout,doesn’tstaywhereit’sput;ANYproblemsrechecktheETT,ETCO2,chestrise

•  BreathSounds&“ChestRise”aresubjecAve&canbemisperceived;“wishfulthinking”

CommonMistake5:AlgorithmConfusionAges&Breakpoints

BIRTH

~1MO

1yr-10kg

8YRS

Puberty

Algorithm NRP

PALS

ACLS

PreferredAEDType

ê

AEDw/PedsDoseA~en’r

AdultAED

ManualDefib

BabyPaddlesunAl1yr/10kg

ChildPaddles/Pads

AdultPads/Paddles

AlgorithmConfusion:Compression/VenAlaAonRaAos

•  30:2foreverybody!•  Except2-RESCUERCHILD&INFANT,inwhichcaseit’s15:2.

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AlgorithmConfusion:“ShouldIStay,OrShouldIGo?”

•  IfALONEwithNOPHONE•  “LEAVEallvicAmstorun,callEMS&comeback!”•  exceptUNWITNESSEDCHILD&INFANT,•  inwhichcaseyoudo2’(5cycles)CPRfirst,THENrun&callEMS&comeback.–  (Wedothese“kickstarter”compressionswithoutdelaybecauseitwasUNWITNESSED,sotheymayhavebeenhypoxicforalongAme,andthey’reCHILD/INFANT,thereforetheyburnO2rapidly.)

6:EquipmentFoibles:SuggestedChecklist:“STATICS-MIMM”

•  S–“Scopes”•  T–“Tubes”•  A–“Airways”•  T–“Tape”•  I– “Introducer”(Stylet)•  C–“Circuit”=srcofPPV(±O2)–  Blender@21%,21-30%blo35wGA

•  S–“SucAon”–  Bulb,Flex,MecAsp

•  M–“Monitors”–  SaO2,ECG,ETCO2;(BP,temp,artline…)

•  I–“IV”/UVC•  M–“Meds”•  M–“Mask”/LMA

PLUS(NRP):•  Warmer•  BabyBaggie<32wks•  NGtubes•  Blankets

CommonMistake7:CommunicaAonBreakdowns

•  Can“somebody”getthemonitorson?•  “Let’s”getoxygenonthispaAent?•  Does“anyone”havethechart?•  Canwegive“some”epinephrine?

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CommunicaAon:AdapAngAirTrafficLingotoNRP

Yamada&Halamek(JPeds2015)

Otherresuscstudiessince2015•  “Balancedfluids”CritCareMed.2017Apr21.doi:10.1097/CCM.0000000000002365.[Epubahead

ofprint]ResuscitaAonWithBalancedFluidsIsAssociatedWithImprovedSurvivalinPediatricSevereSepsis.Comparedto“unbalancedfluids”(NS),“balancedfluids”hadbeYermortality(12.5%vs16%),AKIprevalence(16vs19%)and3.0vs3.3daysonpressors

•  Two-thumb“moreuseful”thantwo-finger(JMaternFetalNeonatalMed.2017Mar5:1-12)•  CurrOpinCritCare.2016Dec;22(6):527-532.FluidresuscitaIonforacutekidneyinjury:anempty

promise.–ratherthanEGDT,anewconceptualmodelisproposed:“Rescue–OpPmizaPon–StabilizaPon– DeescalaPon”.

•  TimePercepIonduringNeonatalResuscitaIon.JPediatr.2016Oct;177:103-7.WeunderesPmatePmeelapsed– whetherwereportfeelingstressedorpreparedornot.

•  ResuscitaAon.2016Oct;107:25-30.doi:10.1016/j.resuscitaAon.2016.07.231.Epub2016Aug2.VenIlaIonfracIonduringthefirst30sofneonatalresuscitaIon.– NorwegianstudyshowingthatPmespentnotvenPlaPngisabout40%infirst30s

•  JPaediatrChildHealth.2016Feb;52(2):141-6.doi:10.1111/jpc.13085.FluidresuscitaIontherapyforpaediatricsepsis.:balancedsoluPonspreferred;colloids=>renaldysfuncPon,shouldbeavoidedforsepsis

•  Targetedtemperaturemanagement:-?Avoidhyperthermia,butin-hospitalcardiacarreststudycalledTHAPCA-IHcompared33vs36.8degC,in-hospitalarrests:disconAnuedearlyforlackofdifferencebeingfound

•  DebriefingFramework:“REFLECT”:Reviewtheevent,EncourageteamparAcipaAon,Focusedfeedback,Listentoeachother,Emphasizekeypoints,Communicateclearly,andTransformthefuture(PediatrEmergCare.2017Apr18)

PICUPearls1.  Ifeverunsureasubtlesignindicatessevereillness,JUST

ASKapediatrician/PICU.Happytochat.2.  Mostcommonsubtlesignsof“sick”kid:

1.  Tachycardia2.  Silenttachypnea(asignofacidosis)3.  SubtlechangesinmentaAon

3.  KidsDECOMPENSATEquickly:“terrifying”4.  HypotensionLATE,VERYOMINOUS,don’tdoubtit;ACT

STAT.5.  Eventeens,whensepAc,o�en+myocardialdysfunxn,

notvasoplegia:needinotropy,notpurepressor6.  MyocardiAscanpresentlikesepsis

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ThankYou

Availableuponrequest