a =. American Neen nan a t Heart POR Curiae i. a CSET (a Pediatric Advanced Life Support ev har as gee a é a LtrPediatric American Heart Associations Advanced Life Support PROVIDER MANUAL Editors Leon Chameides, MD, Conient Consultant Ficardo A, Samson, MD, Associete Science Editor Stephen M. Schesnaydor, MD, Associate Science Ealtor Mary Fran Hazinski, PN, MSN, Senior Science Editor ‘Senior Managing Editor Jennifer Asheraft, RN, BSN Special Contributors Mare D. Berg, MO efirey M, Berman, MD Laure Goniey, BS, RAT, ACP, NPS Allen Fi. de Gaen, MD ‘Aaron Donoghue, MD, MSCE Melinda L. Fiedor Hamiton, MID, MSc Monica €. Kleinman, MD ‘Mary Ann Mctiel, MA, NREMT-P Brenda Schoolfeld, PALS Writer Cindy Tuttle, BN, BSN ‘Salle Young, PharmD, BOPS, Pharmacotherapy Editor © 2011 Amarcan Heart Association ISBN 076-0-67403-527-1 Printed in the United States ot America Fst American Heart Associaton Priving Octobor 2011 10987654321 Pediatric Subcommittee 2010-2011 Mare D. Berg, MD, Chair Monica E. Kloinman, MD, Immediate Past Chair, 2007-2009 ina L. Atkins, MD Kathleen Brown, MD. ‘Adam Cheng, MD Leura Conley, BS, RAT, ROP, NPS. ‘Allan R. de Caen, MD Aaron Donoghue, MD, MSCE Melinda L. Fiedor Hamiton, MD. MSC Ericka L. Fink, MD Eugene B. Freid, MO Cheryl K. Gooden, MD Sharon E Mace, MD Bradley S. Marino, MD, MPP, MSCE Feylon Meeks, RN, BSN, MS, MSN, EMT, PhD Jeffrey M. Perlman, MB, ChE Lester Proctor, MD Faiga A. Qureshi, MD Kennith Hans Sartoretl, MD Wendy Simon, MA Mark A. Terry, MPA, NREMT-P Avoxis Topjan, MD Else W. van der Jagt, MD, MPHParti Course Overview Course Objectives Cognitive Course Objectives Psychomotor Course Objectives Course Description BLS Competency Testing Skills Stations PALS Core Case Discussions and ‘Simulations PALS Core Case Testing Stations Written Exam Precourse Preparation Precourse Self-Assessment BLS Skills ECG Rhythm identification Basic Pharmacology Practical Application of Knowledge to Clinical Scenarios Course Materials PALS Provider Manual PALS Student Website Course Completion Requirements Suggested Reading List 6862088 8m NNN A GS aooe ee Part 2 Systematic Approach to the Seriously Hl or Injured Child Overview Rapid Intervention to Prevent Cardiac Arrest Learning Objectives Preparation for the Course PALS Systematic Approach Algorithm Initial Impression Evaluate-Identify-Intervene Evaluate Identity Intervene Continuous Sequence Determine If Problem Is Life Threatening Primary Assessment Airway Breathing Circulation Disability Exposure Life-Threatening ProblemsInterventions Secondary Assessment Focused History Focused Physical Examination Diagnostic Tests Arterial Blood Gas Venous Blood Gas Hemoglobin Concentration Central Venous Oxygen Saturation Arterial Lactate Central Venous Pressure Monitoring Invasive Arterial Pressure Monitoring Chest X-Ray Electrocaraiogram Echocardiogram Peak Expiratory Flow Rate ‘Suggested Reading List Part 3 Effective Resuscitation Team Dynamics Overview Learning Objectives Preparation for the Course Roles of the Team Leader and Team Members Role of the Team Leader Role of the Team Member Elements of Effective Resuscitation ‘Team Dynamics Closed-Loop Communication Clear Messages Clear Roles and Responsibilities Knowing Limitations Knowledge Sharing SBRBSRRB 8 BBBBBEBBSY Se eee 8 Constructive Intervention Reevaluation and Summarizing Mutual Respect Suggested Reading List Part 4 Recognition of Respiratory Distress and Failure Overview Learning Objectives Preparation for the Course Fundamental Issues Associated With Respiratory Problems Impairment of Oxygenation and Ventilation in Respiratory Problems Physiology of Respiratory Disease Identification of Respiratory Problems by Severity Respiratory Distress Respiratory Failure Identification of Respiratory Problems by Type Upper Airway Obstruction Lower Airway Obstruction Lung Tissue Disease Disordered Contro! of Breathing Summary: Recognition of Respiratory Problems Flowcharts Suggested Reading List Part 5 Management of Respiratory Distress and Failure Overview Learning Objectives Preparation for the CourseInitial Management of Respiratory Distress and Failure Principles of Targeted Management Management of Upper Airway Obstruction General Management of Upper Airway Obstruction Specific Management of Upper Airway Obstruction by Etiology Management of Lower Airway Obstruction General Management of Lower Airway Obstruction Specific Management of Lower Airway Obstruction by Etiology Management of Lung Tissue Disease Goneral Management of Lung Tissue Disease Specific Management of Lung Tissue Disease by Etiology dered Management of Control of Breathing General Management of Disordered Control of Breathing Specific Management of Disordered Control of Breathing by Etiology ‘Summary: Management of Respiratory Emergencies Flowchart Suggested Reading List Resources for Management of Respiratory Emergencies Bag-Mask Ventilation Overview Preparation for the Course How to Select and Prepare the Equipment 49 50 50 ot 52 82 55 87 87 59 61 6 61 61 61 How to Test the Device How to Position the Child How to Perform Bag-Mask Ventilation How to Deliver Effective Ventilation Endotracheal Intubation Potential Indications Preparation for Endotracheal Intubation Part 6 Recognition of Shock Overview Learning Objectives Preparation for the Course Definition of Shook Pathophysiology of Shock ‘Components of Tissue Oxygen Delivery Stroke Volume Compensatory Mechanisms Effect on Blood Pressure Identification of Shock by Severity (Effect on Blood Pressure) Compensated Shock Hypotensive Shock Identification of Shock by Type Hypovolemic Shock Distributive Shock Cardiogenic Shock Obstructive Shock Recognition of Shock Flowchart Suggested Reading List 838 70 nm Rn 2Part 7 Management of Shock Overview Learning Objectives Preparation for the Course Goals of Shock Management Warning Signs Fundamentals of Shock Management Optimizing Oxygen Content of the Blood Improving Volume and Distribution of Cardiac Output Reducing Oxygen Demand Correcting Metabolic Derangements Therapeutic End Points General Management of Shock Components of General Management Summary: initial Management Principles Fluid Therapy ‘sotonic Crystalloid Solutions Colloid Solutions Crystalloid vs Colloid Rate and Volume of Fluid Administration Rapid Fluid Delivery Frequent Reassessment During Fluid Resuscitation Indication for Blood Products Complications of Rapid Administration of Blood Products Glucose Glucose Monitoring Diagnosis of Hypoglycemia Management of Hypoglycemia Management According to. Type of Shock Management of Hypovolemic Shock ‘Management of Distributive Shock ‘Management of Septic Shock Management of Anaphylactic Shock Management of Neurogenic Shock Management of Cardiogenic Shock ‘Management of Obstructive Shock Management of Shock Flowchart Suggested Reading List Resources for Management of Circulatory Emergencies 109 Intraosseous Access 109 Sites for 10 Access 109 Contraindications 109 Procedure (Proximal Tibia) 109 After IO Insertion Color-Coded Length-Based Resuscitation Tape Part 8 Recognition and Management of Bradycardia Overview Learning Objectives Preparation for the Course Definitions Recognition of Bradycardia Signs and Symptoms of Bradycardia ECG Characteristics of Bradycardia Types of BradyarrhythmiasManagement: Pediatric Bradycardia ‘Summary of Emergency With a Pulse and Poor Perfusion Interventions 499 Algorithm 117 Pediatric Tachycardia With a Pulse Identify and Treat Underlying and Adequate Perfusion Algorithm 134 Cause (Box 1) 118 Initial Management (Box 1) 135 Reassess (Bax?) in Evaluate QRS Duration (Box 2) 135 i Adequate Respiration and Perfusion (Box 4a) 118 et con of ari § 195 ip apscycatei rel CespRCAY Treat Cause of SVT (Boxes 7 and 8) 135 ‘Compromise Persist: Perform Wide QRS, Possible VT vs SVT CPR (Box 3) 118 (Boxes 9, 10, and 17) 135 Reassess Rhythm (Box 4) 119 Pharmacologic Conversion vs ‘Administer Medications (Box 5) 119 Eleven! ee a ° iad Pediatric Tachycardia With a Pulse Consider Cardiac Pacing (60x 5) 118 snd Poor Perfusion Algorithm ‘se Treat Underlying Causes (Box 5) 120 Initial Management (Box 1) 4138 Pulseless Arrest (Box 6) 170) Evaluate QRS Duration (Box 2) 138 Suagested Reacing List 10 Treat Cause of ST (Box 6) 138 Treatment of SVT (Boxes 7 and 8) 198 Part 9 Wide QRS, Possible VT (Box9) 139 Recognition and Management Suggested Reading List 139 of Tachycardia 121 Overview 4 ‘ Part 10 Learning Objecti 121 4 SERNOE Recognition and Management Preparation for the Course 121 Of Cardiac Arrest ia Tachyarrhythmias ‘21 Otervion 14 Recognition of Tachyarrhythmias 121 earring Objectives 1 Sinsand Symptoms 1 Preparation for the Course 142 Effect on Cardiac Outout 121 Definition of Cardiac Arrest 142 Classification of Tachycardia and Pathiaya te carcasa’nireat: sao Tachyarthythmias 122 ihepih Management of Tachyarrhythmias 126 Hypoxia om ne aes ve ie 142, Initial Management Questions 126 Sudden Cardiac Arrest Fh ; Causes of Cardiac Arrest 149 Initial Management Priorities 126 ; Recognition of Cardiopulmonary Emergency interventions 126 oe taeRecognition of Cardiac Arrest Arrest Rhythms Management of Cardiac Arrest High-Quality CPR Monitoring for CPR Quality Pediatric Advanced Life Support in Cardiac Arrest Pediatric Cardiac Arrest Algorithm Pediatric Cardiac Arrest: Special Circumsiances Social and Ethical Issues in Resuscitation Family Presence During Resuscitation Terminating Resuscitative Efforts “Do Not Attempt Resuscitation” or “Allow Natural Death” Orders Predictors of Outcome After Cardiac Arrest Factors That Influence Outcome Postresuscitation Management Suggested Reading List Part 11 Postresuscitation Management 171 Overview 471 Learning Objectives Preparation for the Course Postresuscitation Management Primary Goals Systematic Approach Respiratory System Management Priorities General Recommendations Cardiovascular System Management Prioritios General Recommendations PALS Postresuscitation Treatment of Shock ‘Administration of Maintenance Fluids Neurologic System ‘Management Priorities General Recommendations Renal System Management Priorities General Recommendations Gastrointestinal System Management Priorities General Recommendations Hematologic System ‘Management Priorities General Recommendations Postresuscitation Transport Coordination With Receiving Facility Advance Preparation for Transport Infectious Disease Considerations Immediate Preparation Before Transport Communication Between Referring and Receiving Healthcare Providers Communication Among Facilities and With Other Healthcare Providers Communication With the Family Posttransport Documentation and Follow-up Mode of Transport and Transport Team Composition Transport Triage Suggested Reading ListPart 12 Terbutaline 21 | Pharmacology 199 Vasopressin 202 Overview 199 | Preparation for the Course 198 aul Pharmacology pees : a ‘Silonosine noo BLS Competency Testing 238 ‘Alburnin nen ats Skis Testing Sheets ao easel = inal fie Child BLS With “| " a ;cuer itl Alprostadil (Prostegiendin E; (PGE) 203 AED Skills Testing Sheet 234 | ‘Amiodarone: a0 7- and 2-Rescuer Child BLS | Atropine 205 With AED Skills Testing Criteria | Calcium Chioride 207 and Descriotars x ipassineannacons Ba Jeg 2-Rescuer Infant BLS Skiis Dextrose’ (Giana) m0. 1- and 2-Rescuer Infant BLS Skill Diphenhydramine 210 Testing Criteria and Descriptors. 237 Dobutamine 211 Skills Station Competency Depitnie 212 Checklists 230 Epinephrine a Management of Respiratory ' Emergencies Skills Station Etomidate 215 Competency Checkiist 239 Furosemide 216 Rhythm Disturbances/Electrical Hydrocortisone 27 Therapy Skills Station Competency Checkiist 240 Inamrinone (Amrinone) 210 ‘ ; Vascular Access Skills Station Ipratropium Bromide ae Competency Checklist 240 Ddecaine 2m: Rhythm Recognition Review 2a Magnesium Sulfate aan Learning Station Competency Methylprednisolone 222 Checklists 246 Milrinone 220 Respiratory Learning Station iiSnene a Competency Checkists 216 Shock Learning Station Niregyoain 8 Competency Checklists 250 Nitroprusside : ; prussi , Cardiac Learning Station (Sealant Nireprassiag 28 Competency Checklists 254 Norepinephrine 227 PALS Systematic Approach Oxygen 228 = Summary 258 Procainamide 229 Index 261 Sodium Bicarbonate 230Course Overview Course Objectives ‘The Pediatric Advanced Life Support (PALS) Provider Course is designed for healthcare providers who initiate ‘and direct basic through advanced life support. Course ‘concepts are designed to be used throughout the stabil zation and transport phases for both in-hospital and out- ‘of-hospital pediatric emergencies. n this course you wil ‘enhance your skils in the evaiuation and management of an infant or child with respiratory compromise, circulatory compromise, or cardiac arrest. During the course you will actively participate in a series of simulated core cases. These simulations are designed to reinioxce Important concepts, including * Identification and treatment of problems that place the child at risk for cardiac arest + Application of a systematic approach to pediatric assessment ** Use of the “evaluate-identiy-intervene” sequence ** Use of PALS algorithms and flowcharts ‘+ Demonstration of effective resuscitation team dynamics Cognitive Course Objectives Upon successful completion ofthis course, you should be able 10 do the following, independently, when presented with a scenario of aeriticaly il or injured pedietic patent: + Describe the timaly recognition and interventions, required to prevent respiratory and cardiac arrest in any pediatric patient * Describe the systematic approach to pediatric assess~ ment by using the intial impression, primary and sec- ondary assessments, and diagnostic tests * Describe priorities and specific interventions for infants and children with respiratory and/or circulatory ‘emergencies * Explain the importance of elfective team dynamics, including individual roles and responsibilities, during a peciatric resuscitation * Describe the key elements of postresuscitation management Psychomotor Course Objectives Upon successful completion of this course, you should be ‘able to do the following, independently, when presented with a scenario of a criticaly il or injured pediatric patient: + Perform effective, high-quality cardiopulmonary resus- citation (CPR) when appropriate « Perform effective respiratory management within your scope of practice + Select and apply appropriate cardiorespiratory ‘monitoring * Select and admi ister the appropriate medications and electrical therapies when presented with an arshythmia scenario rapid vascular access to administer fluid and ‘+ Demonstrate affective commurication and team dynam- cs both as a team member and as a team leader Pa) The goal of the PALS Provider Course is to improve the quality of care provided to ee aie seriously il or injured children, resulting in improved outcomesCourse Description ‘To help you achieve these objectives the PALS Provider Course includes + Basic life support (BLS) competency testing Skils stations. *+ Core case discussions and simulations + Core case testing stations * Auritten exam BLS Competency Testing You must pass 2 BLS tests to receive an American Heart ‘Association (AHA) PALS Provider course completion card Se ee Pass 1- and 2-Rescuer Child BLS With AED Skills Test + Pass 1- and 2-Rescuer Infant BLS Skills Test ‘The PALS Provider Course does not include detalied instruction on how to perform basic CPR or how to use an automated external defibilator (AED). You must know this in advance. Consider taking a BLS for Healthcare Providers Course if necessary. Before taking the PALS Course, review the student BLS practice sheets and BLS skills testing sheets in the Appendix. Also see Table 1: Summary of Key BLS Components for Adults, Chiléren, and Infants and the Padiatric Cardiac Arrest Algorithm in Part 10: “Recognition and Management of Cardiac Arrest.” Skills Stations The course includes the foliowing skils stations: ‘+ Management of Respiratory Emergencies ‘+ Rhythm Disturbances/Electrical Therapy * Vascular Accoss During the skills stations you will have an opportunity to practice specific skils and thon demonstrate competency. Below is a brief description of each station. During the course you will use the skills stations competency chack- lists while practicing the skills. Your instructor wil evaluate your skills based on the criteria specified in these check- lists. See the Appendix for the sills station chockiste, which list detailed steps for performing each skil. Management of Respir Skills Station tory Emergencies In the Management of Respiratory Emergencies Skils Station you will need to demonstrate your understanding of oxygen (0,) delivery systems and airway adjuncts. You will have an opportunity to practice and demonstrate compe- tency in airway management skils. including * Insertion of an oropharyngeal airway (OPA) + Effective bag-mask ventilation ‘+ OPA and endotracheal (ET) tube suctioning ‘+ Confirmation of advancad airway device placement by ‘hysical examination and an exhaled carbon dioxice (CO,) detector device * Securing tho ET tube {itis within your scope of practice, you may be asked io demonstrate advanced airway skills, including corect inser tion of an ET tube. Rhythm Disturbances/Electrical Therapy Skills Station In the Rhythm Disturbances/Electrical Therapy Skills Station you will have an opportunity to practice and demonstrate ‘competency in rhythm identfication and operation of a car- iac monitor and manual defibrillator. Skills include * Correct placement of electrocardiographic (ECG) leads * Correct paddle/electrode pad selection and placement! positioning * Identification of rhythms that require defibrillation * Identification of rhythme that roquire synchronized cardioversion * Operation of a cardiac monitor * Sale performance of manual defibrillation and synchro: rized cardioversion Vascular Access Skills Station In the Vascular Access Skils Station you will have an ‘opportunity to practice and demonstrate competency in intreosseous (IO) access and other related skills. In this skills station you will * Insert an IO needle + Summarize how to confirm that the needle has entered the marrow cavity + Summariza/demonstrate the method of giving an intra- venous ('V)A0 bolus + Use a color-coded length-based resuscitation tape to calculate correct drug doses PALS Core Case Discussions and Simulations In the learning statiors you wil actively participate in a vari- ‘ety of learning activities, including + Core case discussions using a systematic approach for evaluation and decision making + Cote case simulations {n the learning stations you will apply your knowledge and practice essential skits both individually and as part of a team, This course emphasizes effective team skills as a vital part of the resuscitative effort. You will receive train: ing in effective team behavior and have the opportunity to practice as a team member and a team leader.PALS Core Case Testing Stations At the end of the course you will participate as a team leader in 2 core case testing stations to validate your achiavement of the course objectives. You will be per- mitted to use the PALS pocket reference card and the 2010 Handbook of Emergency Cardiovascular Care tor Healthcare Providers, These SmUlated clinical scenarios will test the following: * Ability to evaluate and identity specttic medical prob- lems covered in the course + Recognition and management of respiratory and shook emergencies + Interpretation of core arthythmias and management using appropriate medications and electrical therapy * Performance as an effective team leader ‘A major emphasis of this evaluation will be your ability to direct the integration of BLS and PALS skils by your team members according to their scope of practice. Review Part 2: “Effective Resuscitation Team Dynamics” before ‘the course. Written Exam ‘The writen exam evaluates your mastery of the cognitive objectives. The written exam is closed-book; no resources or aids are perritted. You must score 84% or higher on the written oxam. Precourse Preparation “To successtully pass the PALS Provider Course, you must prepare before the course. Do the following: + Takeo the Precourse Self-Assessment + Make sure you are proficiant in BLS skils. + Practice identifying and interpreting core ECG rhythms, + Study basic pharmacology and know when to use which drug. + Practice applying your knowledge to ctnical scenarios. Precourse Self-Assessment Se neil: 6 eae Se see eee Serer meee ear BLS Skills ‘Strong BLS skills are the foundation of advanced life sup- port. Everyone involved in the care of pediatric patients ‘must be able to perform high-quality CPR, Without high- quality CPR, PALS interventions will fail. For this reason, each student must pass the 1- and 2-Rescuer Child BLS With AED and 1- and 2-Rescuer Infant BLS Skill Tests in the PALS Provider Course. Make sure that you are proficient in BLS skils before attending the course. ‘See the section "BLS Competency Testing” in the Appendix: {or testing requirements and resources. ECG Rhythm Identification ‘You must be able to identify and interpret the following core ‘hytbms during case simulations and core case tests: = Normal sinus rhythm Sinus bradycardia Sinus tachycardia Supraventricular tachycardia * Ventricular tachycarcia * Ventricular fioitation + Asystole ‘The ECG rhythm identifcation section of the Precourse ‘Self-Assessment will help you evaluate your ability to identify these core rhythms and other common pediatric arrhythmias. if you have difficulty with pediatric rhythm identiication, improve your knowledoe by studying the sec- tion “Rhythm Recognition Review” in the Appendix. The AHA also offers self-directed online courses on rhythm ree- cognition. These courses can be found at OnlineAHA.org. Basic Pharmacology ‘You must know basic information about drugs used in the PALS algorithms and flowcharts. Basic pharmacology information includes the indications, contraindication, and methods of administration. You will need to know when to use which drug based on the clinical situation. ‘Tho pharmacology section of the Precourse Self- Assessment will help you evaluate and enhance your knowledge of mecications used in the course. If you have difficulty with this section of the Precourse Self- Assessment, improve your knowledge by studying the PALS Provider Manual and the 2010 Handbook of Emergency Cardiovascular Care for Healthcare Providers.Practical Application of Knowledge to Clinical Scenarios ‘The practical application section of the Precourse Self Assessment wil help you evaluate your ability to apply your kaowledge when presented with 2 clinical scenaro, You wil need to make decisions based on + Tho PALS Systematic Approach Aigorthm and the evaluate-identify-niervene sequence + identication of core rhythers + Knowledge of core medications + Knowledge of PALS flowcharts and algorithms Be sure that you understand the PALS Systematic PALS Student Website, and 2010 Handbook of Emergency Cardiovascular Care for Healtncare Providers. Course Materials Tho PALS Provider Course matotials consist of the PALS Provider Manual and supplementary material on the PALS. Student Webstte PALS Provider Manual The PALS Provider Manual contains material that you will use before, during, and after the course. It contains impor- tant information that you need 10 know to effectively par= ticipate in the course, so please read and study the manual before the course. This important material includes con- cepts of pediatric evaluation and the recognition and man- ‘agement of respiratory, shock, and carciac emergencies. ‘Some students may already know much of this information; others may need extensive study before the course. ‘Approach Algorithm and the evaluate-identity-intervene sequence, Review the core rhythms and medications. Be familar with the PALS algorithms and flowcharts so that you can apply them to clinical scenarios. Note that the PALS Course Goes not teach the details of each algorithm. Sources of information are the PALS Provider Manua, The manual is organzed into the following parts: fea Gok eee ee Course Overviow What you need to know before the course, how to prepare for the course, and what to expect during the course The PALS systematic approach, intial impression, evaluate-identity-inter- vene sequence, including the primary assessment, secondary assessment, and diagnostic tests ‘Systematic Approach to the Seriously Ill or Injured Child Effective Resuscitation Team Dynamics Recognition of Respiratory Distress and Failure Roles of team leader and team members; how to effectively communicate as a team leader or team member Basic concepts of respiratory cistross and failure; how to identity respica- tory problems according to type and severity Management of Respiratory Intervention options for respiratory problems and emergencies Distress and Failure Recognition of Shock Basic concepts of shock; shock identification according to type and severity Management of Shock Recognition and Management of Bradycardia Intervention options for shock according to etiology Clinical and ECG characteristics of bradyarthythmias; medical and electri- cal therapies Recognition and Management of Tachycardia Clinical and ECG characteristics of tachyarihythmias; medical and electr- cal thorapios | ‘Signs of cardiac arrest and terminal cardiac rhythms; resuscitation and electrical therapy Recognition and Management of Cardiac Arrest Postresuscitation Management —_| Postresuscitation evaluation and management; postresuecitation traneport Pharmacology Appendix Details about common medications used in pediatric emergencias Checklists for BLS competency testing, skit stations competencies, and core case simulations; a brief rhythm recognition reviewThroughout the PALS Provider Manual you will find specitic information in the following types of boxes: ‘Type of Box Coe td Cee Remember to take this manual with you to the course. PALS Student Website mation about basic PALS concepts, Eg rg ‘The Precourse Self-Assessment isa vital part of your preparation for the course. Feedback from this assessment will help yu identfy gaps in your knowledge so that you can target specific material to study. eed eee eta a Pe led the Course + Pharmacology Course Completion Requirements To successfully complote the PALS Provider Course and obtain your course completion card, you must do the folowing: * Actively participate in, practice, and complete all skills stations and learning statons + Pass the 1- and 2-Rescuer Child BLS With AED and 1 and 2-Reaouer Infant BLS Skills Tests + Pass a virtton exam with a minimum score of 84% + Pass 2 PALS core caso tests as a team leador Suggested Reading List Donoghue A, Nishisaki A, ution R, Hales A, Boulet J Relitilty end validity of a scoring instrument for clinical performance during Podiatric Advanced Life Support simu- lation seenaros. Resuscitation. 2010;81:331-896, ‘Basic information that every PALS provider should know Important core concepts that are key to caring for critically ill or injured children, ‘An important evaluation or an immediate lifesaving intervention ‘Advanced information that you can use to increase your knowledge but that is not required for successful course participation @ Go to the PALS Student Website to access the Precourse Self-Assessment, Here you will also find additional infor- ‘The URL for the PALS Student Website is www.heart.orgiecestudent ‘To enter the webstte, you will need the access code found at the bottom of page it in the front of your PALS Provider Manual. ‘The Precourse Self-Assessment has 3 parts: + ECG rhythm identiication * Practical application Complete these assessments before the course to identify gaps in and improve your knowledge. Print out your certificate of completion and take it with you to the course. Hunt EA, Vera K, Diener-West M, Haggerty JA, Nelson KL, Shatfner DH, Pronovost Pu. Delays and errors in car diopulmonary resuscitation and defibrillation by pediat- ric residents during simulated cardiopuimenary arrests. Resuscitation. 2009;80:819-625. Niles D, Sutton RM, Donoghue A, Kalsi MS, Roberts K, Boyle L, Nishisaki A, Arbogast KB, Helfaer M, Nadkami V. “Rolling Refreshers”: a novel approach to maintain CPR psy- chomotor skill competence. Resuscitation. 2009:80:909-912, Roy KM, Miler MP, Schmit K, Sagy M, Pediatric residents ‘experience a significant dectine in their response capabii- ties to simulated life-threatening events as their training frequency in cardiopulmonary resuscitation decreases [pupisned online ahead of print October 1, 2010]. Peotatr Crit Care Med. doi 10.1097/PCC.0b0198318113a0dSutton RM, Niles D, Meaney PA. Aplenc R. French 8. Abella BS, Lengetti EL, Berg RA, Helfaer MA, Nadkarn) \V. "Booster" training: evaluation of instructor-led bedside cardiopulmonary resuscitation skill training end automated corrective feedback to improve cardiopulmonary resuscita- tion compliance of Pediatric Basic Life Support providers ‘during simulated cardiac arrest (oublished online ahead Of print July 8, 2010), Pediatr Crit Care Med. doi10.1097/ PCC.0b013e818 1691271Systematic Approach to the Seriously Ill or Injured Child Overview ‘The PALS provider should use a systematic approach when Caring fora seriously i or injured child, The purpose of this crganized approac isto enable you to quickly recognize signs of respiratory distress, respiratory failure, and shock and inmediatoly provide lifesaving intorventions. If not appropriately treated, children with respiratory failure and shock can quickly develop cardiopuimonayy failure and even cardiac arest (Figure 1). Rapid Intervention to Prevent Cardiac Arrest In infants and children, most cardiac arrests result from pro- gressive respiratory failure, shock, or both. Less commonly, Pediatric cardiac arrests can occur without warning (ie, with ‘sudden collapse) secondary to an arrhythmia (ventricutar fibrilation (VF or ventricular tachycardia [VT). ‘Once cardiac arest occurs, even with optimal resuscitation cfforts, the outcome is generally poor. In the out-of-hospital setting only 4% to 13% of children who experience cardiac arrest survive to hospital discharge. The outcome is better {or children who experience carclac arrest in the hospital, although oniy about 33% of those children survive to hos pital discharge. For this reason itis important to learn the concepts prasentod in the PALS Provider Course so that Rapid, systematic intervention for seriously ill or injured infants and children is Key to preventing progression to cardiac arrest. Such rapid intervention can save lives. you can identity signs of respiratory feilure and shock and. rapidly intervono to prevent progression to cardiac arrest. Learning Objectives ‘After completing this Part you should be able to * Discuss the evaluate-identiy-intervene sequence ‘+ Explain the purpose and components of the initial improssion '* Describe the ABCDE components of the primary assessment * Interpret the clinical findings during the primary ‘assessment * Evaluate respiratory or circulatory problems by using the ABCDE mode! in the primary assessment + Describe the components of the secondary assessment * List diagnostic and laboratory tests used to identify respiratory and circulatory problems Preparation for the Course ‘You rieed to know all of the concepts presented in this Part to be able to identify respiratory or circulatory problems ‘and target appropriate managomont in case simulations. ‘The ongoing process of evaluate-identfy-intervene is a core ‘component of systematic evaluation and care of a seriously i oF injured child,Precipitating Problems Respiratory Circulatory Sudden Cardiac Arrest (Arrhythmia) Figure 1. Pathways to pediatic cardiac arest. Note that respiratory problems may progress to respiratory falure wth or witout signs of resp= ratory distess, Pespratory failure without respiratory dstiess ozcurs when the chld falls to maintain an open alway oF adoquate respiratory afort and is typically associated with a decreased Iavelo! consciousness. Sudden cardiac arrestin chieren is less common than in aduls and typically resus from arhythmias such as VF or VT. Ouring sports activities, sudden cavdlac arest ean occur in children with underlying cardige problems ‘hat may oF may not have bean previously recogrized.Se een a a oe Red ALS Systematic Approach Algorithm ‘The PALS Systematic Approach Algorithm (Figure 2) outlines the approach to cating for a critically il or injured child. Initial Impression ‘Activate Emergency Response 18 appropriate for setting) Goto Pediatric Cardiac Arrest Algorithm ‘After ROSC, begin Evaluate-Identity-Intorvene ‘sequence (right column) ©2011 Amaroan Heat Aosocaton Figure 2. PA.5 systematic Approach Algor, If at any time you identify a life-threatening problam, immediately begin appropriate Interventions. Activate emergency response as indicated in your practice setting,Initial Impression The initial impression (Figure 2) is your first quick “trom the doorway” observation. Ths inital visual and aucitory obser- provide compressions and ventilations. Proceed ‘according to the Pediatric Cardiac Arrest Algorithm. 1» If the heart rate is 260/min, begin the evaluate- identity-intervene sequence. Be prepared to inter- vene according to the Pediatric Cardiac Arrest | Algorithm if needed, | « Ifthe child is breathing adequately, proceed with the evaluate-identify-intervene sequence. If at any time you identify cardiac arrest, begin CPR and proceed accord- vation of the chilo's consciousness, breathing, and color is accomplished within seconds of encountering the child. ees Consciousness | Leve! of consciousnoss ing to the Pediatric Cardiac Arrest Algorithm. (¢9, unresponsive, iritable, alert) [resting | wreesed wacof treating, coset | Ewaluate-Identify-Intervene cr decreased respiratory effort, or Use the evaluate-identify-intervene sequence (Figure 3) ‘abnormal sounds heard without | when caring fora seriously il or injured child. This wil helo auscuttation you to determine the best treatment or intervention at any ———— point. From the information gathered during your evaluation, Soler ‘Abnormal skin Color, Such a5 yaNO- | identity the child’s problom by type and severity. Intervene Ss pelos erring with appropriate actions. Then repeat the sequence. This process is ongoi ‘The level of consciousness may be characterized as unre- ee sponsive, irtable, or alert. Decreased lavel of conscious- ness may result from inadequate O, or substrate delivery or brain trauma/dystunction. Abnormal breathing includes use ‘of accessory muscles, extra sounds of breathing, or abnor- ‘mal breathing patterns. Pale, mottied, or bluish/gray skin color suggests poor parfusion, poor oxygenation, or both. A flushed appearance suggests fever or the presence of atoxin. Use your intial impression to determine the next best stops: « If the child is unresponsive and not breathing or only gesping, shout for help or activate emergency response {as appropriate for your practice setting). Check to see if there is a pulse. ~ If there is no pulse, start CPR, beginning with chest ‘compressions. Proceed according to the Pediatric Cardiac Arrest Algorithm. Alter return of spontane- us circulation (FOS), begin the evaluate-identify- intervene sequence. ~ Ifa pulse is present, provide rescue breathing. ‘=f, despite adequate oxygenation and ventilation, the bear rate is <60/rmin with signs of poor perfusion, Figure 3. Evaluate-derify- intervene sequence. Always be alert to a life-threatening problem. if at any point you identify a life-threatening problem, immediately activate ‘emergency response (or send someone to do so) while you begin lifesaving interventions. oa The initial impression used in this version of the PALS Provider Course is a modification Of the Paciatric Assessment Triangle (PAT) that was used in the 2008 PALS Provider Course.* The PAT, lke the rapid cardiooulmonary essessment (which was taught in all Of the PALS courses before 2006),’is part of a systerratic approach to assessing an il © injured child. These slightly different assessment approaches use many of the same ‘common terms. The goal ofall of these approaches is to help the provider quickly rec- ‘ognize a chi at risk for deterioration and prioritize actions and interventions. tee ‘Dieckmann RD, Brownstein OR, Gausche-HillM, eds. Pediatric Education fr Prehospta! Professionals Insttuctor Took. Sudbury. MA: American Academy of Pedi and Jones & BBarlet Publishers; 2000. ‘Ralston M, Hazinski MF, Zarsky AL, Schexrayder SM, Klerman ME ‘eds, Peclatic Advanced Life Support Provider Manual. Dallas, TX: American Heart Assocation; 12000. Hazinski MF, Zantsky AL, Nadkarni VM, Hickey RW, Schexnayder SM, Berg RA, eds Pediatric Advanced Life Support Prove Manual. Dalia, TX: American Heatt Asscciaton: 2002.SC ene Ue ae Rd Evaluate It no ife-threatening problem is present, evaluate the child's condition by using the clinical assessment tools described below. re pinay Cea Primary A rapid, hands-on ABCDE approach assessment | to evaluate respiratory, cardiac, and neurologic function; this step includes assessment of vital signs and pulse oximetry Secondary —_| A focused medical history and a assessment | focused physical exam. Diagnostic | Laboratory, radiographic, and other tests ‘advanced tests that help to identify the child's physiologic condition and diagnosis Note: Providers should be aware of potential environmental dangers when providing cars. In out-of-hospital settings, always assess the scane before you evaluate the child. Identify Try to identify the type and severty of the chic's problem. vid Ee Respiratory | * Uppor airway = Respiratory obstruction cistress * Lower airway * Respiratory obstruction failure * Lung tissu disease * Disordered control of breathing Circulatory | + Hypovolemic shook ‘+ Compensated * Distributive shook | shock *# Cardiogenic shock | * Hypotensive shock *# Obstructive shock Cardiopulmonary Failure Cardiac Arrost The child's ciinical condition can result rom a combination of respiratory and circulatory problems. As a seriously il or injured child deteriorates, one problem may lead to others. eka Ty ROS Ca Le * Alter each intervention Intervene Sequence Is erates Note that in the initial phase of your identification you may bbe uncertain about the type or soverty of problems. Identifying the problem will help you determine the best initial interventions. Recognition and management are dis cussed in deal later in this manual, Intervene (On the basis of your identiication of the child's problem, intervene with appropriate actions within your scope of practice. PALS interventions may include ‘ Positioning the child to maintain a patent airway ‘* Activating emergency response * Staring CPR + Obtaining the code cart and monitor + Placing the child on a cardiac monitor and pulse oximeter «= Administering O. ‘Supporting ventilation * Starting medications and fluids (eg, nebulizer treatment, IV/1O fuuid bolus) Continuous Sequence The sequence of evaluate-identily-intervene continues Until the chid is stable. Use this sequence belore and atter each intervention to lack for trencs in the child's condktion. For example, after you give O., reevaluate the chid. is the CChid breathing a lite easier? Ave color end mental status improving? After you give a flid bolus to a child in hypo- volemic shock, do heart rate and perfusion improve? Is. ‘another bolus neadec? Use the evaluate-identily.intervene ‘sequence vibenever the child's condition changes. Determine If Problem Is Life Threatening ‘On the basis of the initial impression and throughout care, determine ifthe child's problem is «Lite threatering * Not life threatening Life-threatening probleme include absent or agorsal res pirations, respiratory distress, cyanosis, or decreased level of consciousness (see the section “Lite-Threatenng Problems" later inthis Part). If the problem is life threaten- ing, immediately begin appropriate interventions. Activate ‘emergency response as indicated in your practice setting It the problem ss not if threatening, continue with the sys- tematic approach. Remember to repeat the evaluate-identify-intervene soquence until the child is stable + When ihe child's concition changes or deterioratesa ‘Sometimes a child's condition may saem stable despite the presence of a lfe-threat- ening problem, An example is @ child who has ingested a toxin but is not yet snowing effects, Another example is a trauma victim with internal bleeding who may initially mainiain blood pressure by increasing heart rate and systemic vascular resistance (SVF). eee Retry Ie Ou cu) Primary Assessment A B E c D ‘The primary assessment uses an ABCDE model: + Ainway + Broathing * Circulation + Disability + Exposure ‘The primary 2esessment is a hands-on evaluation of respiratory, cardiac, and neurologic function. This assoss- ‘ment includes evaluation of vital signs and O, saturation by pulse oximetry. Airway When you assess the ainay, you determine if it is patent (open). To assess upper airway patency: * Look for movement of the chest or abdomen * Listen for air movement and breath sounds Decide if the upper airway is clear, maintainable, or not ‘maintainable as described in the following table: pe Clear Airway is open and unobstructed for normal breathing Maintainable | Airway |s obstructed but can be main- tained by simple measures (eg, head tilt-chin It) Not Airway is obstructed and cannot be maintainable | maintained without advanced interven- tions (eg, intubation) ‘The following signs suggest that the upper airway is obstructed: + Increased inspiratory effort with retractions ‘+ Abnormal inspiratory sounds (snoring or high-pitched stridor) + Episodes where no airway or breath sounds are pres- ‘ent despite respiratory effort (le, complete upper airway obstruction) If the upper airway ie obstructed, determine if you can open land maintain the airway with simple measures or if you need advanced interventions. ‘Simple measures to open and maintain a patent upper air- way may include one or more of the following: + Allow the child to assume a position of comfort or posi- ton the child to improve airway patency. + Use nead tit-chin lft or jaw thrust to open the airway. ~ Use the head tit-chin lft maneuver to open the a ‘way unless you suspect cervical spine injury. Avoid overextending the head/neck in infants because ths may ecclude the airway. ~ Hf you suspect cervical spine injury (eg, the chi has head or neck injury), open the away by using a jaw ‘thrust without neck extension. If this maneuver does. not open the airway, use a head tit-chin lift or jaw ‘trust with neck extension because opening the ai. \way is a prio. During CPR stabilize the head and neck manually rather than with immobikzation devicos. I at any time you identity a life-threatening problem, immediately begin appropriate interventions. Activate emergency response as indicated in your practice setting— Note that the jaw thrust may be used in children without trauma as vrell, ‘Avoid overextending the head/neck in infants because this may occlude the airway. Suction the nose and ‘oropharynx. Perform foreign-bedy airway obstruction (FBAO) relief techniques if you suspect that the child has aspirated a foreign body, has complete airway obstruction ($ tunable to make any sound), and is stil responsive, Repeat the folowing es needed: ~ <1 year of age: Give 5 back slaps and 5 chest thrusts = 21 year of aga: Give abdominal thrusts Use airway adjuncts (eg, nasopharyngeal airway [NPA] or oropharyngeal airway [OPA)) to keep the tongue {rom falling back and obstructing the airway. Advanced Interventions Advanced interventions to maintain airway patency may include one or more of the following: ‘+ Encotracheal intubation or placement of a laryngeal mask airway ‘+ Application of continuous positive airway pressure (CPAP) or noninvasive ventilation ‘+ Removal ofa foreion body: this intervention may requite drect laryngoscopy (ie, visualizing the larynx with a laryngoscope) * Cricothyrotomy (a needle puncture or surgical opening through the skin and criecthyroid membrane and into’ the trachea below the vocal cords) Breathing Assessment of breathing includes evaluation of * Respiratory rate * Respiratory effort * Chest expansion and air movement Cred DOO CAC Cee ie el ‘An airway adjunct will help to maintain an open airway, but you may stil need to use a head tit-chin lift. Don't rely only on an adjunct alone, Assees the pati Acconsistent respiratory rate of less than 10 or more than 60 breaths/min in a child of any age is abnormal and suggests the presence of a potentially serious problem. SS ee RGR ae Ee eked * Lung and airway sounds ‘+ 0, saturation by pulee oximetry Normal Respiratory Rate Normal spontaneous breathing is accomplished with mini ‘mal work, resulting in quiot breathing with unlabored inspi- ration and passive expiration. The normal respiratory rate Inversely related to age (see Tabie 1); it is rapid in the neo- ate and decreases as the chiki gets older. Table 4. Normal Respiratory Rates by Age oS Breaths/min [event et yoo) 01080 Toddler (1 to 3 years) 24 to 40 Preschooler (4 to 5 years) 221034 School age (6 to 12 years) 180.90 | Adolescent (13 to 18 years) 121016 Respiratory rate is often best evaluated before your hands- on assessment bacause anxiaty and agitation commonly alter the baseline rata. Ifthe child has any condition that causes an increase in metabolic demand (eg, excitement, anxiety, exercise, pain, or fever), itis appropriate for the respiratory rate to be higher than normal. Determine the respiratory rate by counting the number of times the chest rises in 30 seconds and multiplying by 2. Be aware that normal sleeping intents may have irregular (periodic) breathing with pauses lasting up to 10 or even 16 seconds. If you count the number of times the chest rises for <30 seconds, you may estimate the respiratory rate inaccurately. Count the respiratory rate several timas ‘as you assess and reassess the child to detect changes. Alternatively, the respiratory rate may be displayed continu- ‘ously on a monitor. A decrease in respiratory rate from 2 rapid to a more “normal” rate may indicate overall improvement if itisassociated with an improved level of consciousness and reduced signe of air hunger and work of breathing. A decreasing or irregular respiratory rate in a chid with a deteriorating level of consciousness, however, often indi cates a worsening of the child's clinical condition. Abnormal Respiratory Rate ‘Abnormal respiratory rates are classified as + Techypnea + Bradypnea + Apnea Tachypnea Tachypnea is a breathing rate that is more rapi than nor- ‘mal for age. It is often the first sign of respiratory distress in Infants. Tachypnea also can be a physiologic (appropriate) response to stress. Tachypnea with respiratory distress is, by definition, associ ated with other signs of increased respiratory effort. “Quiet tachypnea” is the term used if tachypnea is present without signs of increased respratory effort (e, without respiratory distress). This often results from an attempt to maintain near-normal blood pH by increasing the amount of air mov- ing in and out of the lungs (ventilation) this decreases GO. leve's in the blood and increases biood pH. Quiet tachypnea commonly results from nonpulmonary problems, including * High fever » Pan ‘+ Mild metabolic acidosis associated with dehydration or diabetic ketoacidosis (DKA) ‘+ Sopsis (without pnaumonia) * Congestive heart failure (early) * Severe anemia * Some cyanotic congenital heart defects (eg. transposi- tion of the great arteries) eee See aa cd Rega eel Signals Impending Arrest a7 resent: eee ae apnea Bradypnea cr an irregular respiratory rate in an acutely il infant or chile is an ominous, clinical sign and often signals impending arrest. | ‘Apnea is classified into 3 types, depending on whether inspiratory muscle activity * In central apnea there is no respiratory effort because of an abnormality or sup pression of the brain or spinal cord, ® In obstructive apnea there is inspiratory eftort without airflow (ie, airflow is partially ‘or completely blocked). ‘= In mtxed apnea there are poriods of obstructive apnea and periods of contral for age, Frequontly the breathing is both slow and iregu- lar, Possible causas are respiratory muscle fatigue. central ‘nervous system injury or infection, hypothermia, or medica- tions that depress respiratory drive. | Apnea ‘Apnea is the cessation of breathing for 20 seconds or ces- sation for less than 20 seconds i accompanied by brady- cardia, cyanosis, or pallor. Bradypnea Bradypnea is a breathing rate that is slower than normal ‘Agonal gasps are common in adults after sudden cerdiac arrest and may be confused with normal breathing. Agonal ‘gasps will not produce effective oxygenation and ventilation. Respiratory Effort Increased respiratory effort results from conditions that increase resistance to airflow (eg, asthma or bronchiclitis) cr that cause the lungs to be stiffer and difficult to inflate (e9, pnoumoria, pulmonary edema, or pleural effusion) Nonpulmonary conditions that result in severe metabolic acidosis (€g, DKA, sabcylate ingestion, indorn errors of metabolism) can also cause increased respiratory rate and effort. Signs of increased respiratory effort retlect the child's attempt to improve oxygenation, ventilation, or both, Use the presence or absence of these signs to assess the severity of the condition and the urgency for intervention. Signs of increased respiratory effort include ‘= Nasal flaring ‘+ Retractions ‘+ Head bobbing or seesaw respirations thor signs of increased respiratory effort are prolonged inspiratory or expiratory times, open-mouth breathing, ‘gasping, and use of accessory muscles. Grunting Is a serl- ‘ous sign and may indicate respiratory distress or respiratory failure, (See “Grunting” later inthis Part.)‘Systematic Approach to the Seriously Ill or Injured Child Nasal Flaring (continued) ‘Nasal faring is dation of the nostri with each inhalation, Pe cc ‘The nostris open more widely to maximize airflow. Nasal Cre aed flaring is most commonly observed in infants and younger chilcron and is usually a sign of respiratory distress. Severe (may | Supraciavicular | Retraction in the include the ‘neck, ust above the Retractions same retrac- collarbone Retractions ere inward movements of the chest wallortis- | tlorsasseen [sr atermal | Retraction in the sues, neck, oF sternum ding inspiration. Chest retractions | With mil chest, just above are a sign that the child is trying to move air tothe turgs | tomoder- the breastbone by using the chest muscies, but air movement is impaired ate breathing by increased airway resistance or stif lungs. Retractions aiticury) Sternat Retraction of the ‘may occur in several areas of tho chest. The severity of the ctor foward the spine retractions generally corresponds with the severity of the child's breathing difficuty. Head Bobbing or Seesaw Respirations “The following table describes the location of retractions Head bobbing and seesaw respirations often indicate that ‘commonly associated with each level of breathing difficulty: the child has increased risk for deterioration + Heed bobbing is caused by tho uso of neck muscles Ca eee pete (rete to assist breathing. The child lits he chin and extencs the neck during inspiration and allows the chin to fal ‘Subcostal Ratraction of the forward during expiration. Head bobbing is most tre= | abdomen. just quently seen in infants and can be @ sign of respiratory Delow the rib cage falure | + Seesaw respirations are present when the chest | Substernal_ | Retraction of the retracts and the abdomen expands during inspiration. abdomen at the During expiration the movement reverses: the chest bottom of the ‘expands and the abdomen moves inward. Soesaw respirations usvally indicate upper airway obstruction, Pression: They also may be observed in severe lower airway intercostal | Retraction betweon obstruction, lung tissue disease, and disordered control the rbe | Of breathing, Seesaw respirations are characteristic al J Of infants and children with neuromuscular weakness. (continued) Tis inefficient form of ventlation can cuiekly lead to fatigue. a etvactions accompanied by stridor or an inspiratory snoring sound suggest upper ih airway obstruction. Retractions accompanied by expratory weezing suggest marked ans ower airway obstruction (asthma or bronchiolitis), causing obstruction during both Renee USE Reus RPO cu ala Peer ego inspiration and expiration, Retractions accompanied by grunting or labored respira- tions suggest lung tissue disease. Severe retractions also may be accompanied by head bobbing or seesaw respirations, The cause of seesaw breathing in mest children with neuromuscular disease is weak~ ness of the abdominal and chest wall muscles. Seesaw breathing Is caused by stiong contraction of the diaphragm that dominates the weaker abdominal and chest wall muscles. The result is retraction of the chest and expansion of the abdomen during inspiration. oe td Eee eee)Chest Expansion and Air Movement Evaluate magnitude of chest wall expansion and air move~ ment to assess adequacy of the chile’s tidal volume. Tidal volume is the volume of air inspired with each breath, Normal tidal volume is approximately 5 to 7 mL/kg of body weight and remains fairy constant throughout Ife, Tidal volume is difficult to measure unless a child is mechanically ventilated, so your clinical assessment is very important, Chest Wall Expansion Chest expansion (chest rige) during inspiration should be symmetric. Expansion may be subtle during spontane ‘ous quiet breathing, especially when clothing covers the chest. But chest expansion should be readily visible when the chest is uncovered. In normal infants the abdomen ‘may move moro than the chest. Decreased or asymmetric cchest expansion may result from inadequate effort, ainway obstruction, atelectasis, pneumothorax, hemothorax, pleu- ral effusion, mucous plug, or foreign-body aspiration, Air Movement ‘Auscuttation for air movement is critical. Listen for the intensity of breath sounds and quality of air movement, Particularly in the cistal lung fields. To evaluate distal ar entry, Isten below both axillao. Because these areas are farthest from the larger conducting airways, upper airway Sounds are less likely to be transmitted. Typical inspiratory ‘sounds can be heard distally as soft, quiet noises ocour- ring simultaneously with observed inspiratory effort. Normal ‘expiratory breath sounds are often short and quiets. ‘Sometimes you may not hear normal expiratory breath sounds. You should also auscuitate for lung and airway sounds ver the anterior and posterior chest. Because the chest is small and the chest wall is thin in infants or children, breath ‘sounds are readily transmittad from one side of the chest to tne other, Breath sounds also may be transmitted from the upper airway. Decreased chest excursion or decreased air movement observed during auscultation often accompanies poor + Stow respiratory rate *+ Small tical volume (ie, shallow breathing, high airway resistance, stft lungs) + Extremely rapid respiratory rate i tidal volumes are very small) Minute ventilation is the volume of air that moves into or out of the lungs each minute, {tis the product of the number of breaths per minute (respiratory rate) and the volume of each breath (ida! volume) Minute Ventilation = Respiratory Rate x Tidal Volume Low minute ventilation (hypoventilation) may result from respiratory effort. In tho child with apparently normel or increased respiratory effort, diminished distal air entry ‘Suggests airflow obstruction or lung tissue disease. If the child's work of breathing and coughing suggest lower al- way obstruction but no wheezes are heard, the amount and rate of airflow may bo insufficient to cause wheezing, Distal ir entry may be dificult to hear in the obese child. As a result, it may be difficult to identify significant airway abnormalities in this population Lung and Airway Sounds During the primary assessment, listen for lung and airway sounds. Abnormal sounds include stridor, grunting, gur- gling, wheezing, and crackles. Stridor Strider is a coarse, usually higher-pitched breathing sound typically heard on inspiration. It also may be heard during both inspiration and expiration. Stridor is a sign of upper airway (extrathoracic) obstruction and may indicate that the obstruction is critical and requires immediate intervention. ‘Thote ave many causes of stridor, such @s FBAO and infec tion (eg, croup). Congenital airway abnormalities (eg, laryn- omaiacia) and acquired airway abnormalities (2g, tumor Cr cySt) also can cause stridor. Upper airway edema (eg, allergic reaction or swelling after a medical procedure) is ‘another cause ofthis abnormal breathing sound. Grunting Granting is typically a short, low-pitched sound heard uring expiration. Sometimes it can be misinterpreted as a soft ory, Grunting occurs as the child exhales against a partialy closed glottis. Although grunting may accompany the response to pain or fever, infants and children often grunt to help keep the small aways and alveolar sacs in the lungs open. This is an attempt to optimize oxygenation and ventilation, Grunting is often a sign of lung tissue disease resuting from smal airway collapse, alveolar collapse, or both. Grunting may indicate progression of respiratory distress touel eon ni na Rem a Rel] Grunting is typically a sign of severe respiratory distress or failure from jung tissue disease. Identity and treat the cause as quickly as possible. Be prepared to quickly intervene If the chila's condition worsens. respiratory failure. Pulmonary conditions that cause grunt ing include pneumonia, pulmonary contusion, and acute respiratory distress syndrome (ARDS). It may he caused by ‘cardiac conditions. such as congestive heart faiure, that result in pulmonary edema. Grunting may be a sign of pain resulting from abdominal pathology (eg, bowel obstruction, porforated viscus, appendicitis, or peritonitis). Gurgling Gurgling is a bubbing sound heard during inspiration or ‘expiration. It results from upper airway obstruction due to airway secretions, vomit, or blood. Wheezing Wheezing is a high-pitched or low-pitched whistling or sigh: ing sound heard most often during expration. itis heard less frequently during inspiration. This sound typically ind- cates lower (intrathoracic) airway obstruction, especially of the emaller aways. Common causes of wheezing aro bron: chioitis and asthma. Isolated inspiratory wheezing suggasts ‘a foreign body or other cause of partial obstruction of the trachea or upper airway. Crackles Grackies, also known as rales, are sharp, crackling inspira- tory sounds. The sound of dry crackles can be described as the sound made when you rub several hairs together close to your ear. Crackles may be described as moist or dry. Moist crackles indicate accumulation of alveolar fluid, ‘They are typically associated with lung tissue disease (eg, pneumonia and pulmonary edema) or interstitial lang ured OME Ty disease. Dry crackles are more often heard with alelectasis (smal airway collapse) and interstitial lung disease. Noto that you may not hear crackles despite the presence of pulmonary edema, Oxygen Saturation by Pulse Oximetry Pulse oximetry is a tool to monitor the percentage of the child's hemogiobin that is saturated with O, (Spo). The pulse oximeter consists of a probe Inked to a monitor. The probe is attached to the child's finger, toe, or earlobe. The unit displays the calculated percentage of oxygenated hemoglobin. Most units make an audiole sound for each pulse beat and display the heart rate. Some models display the quality of the pulse signal as a waveform or with bars. Pulse oximetry can indicate low ©, saturation (hypoxemia) before it causes cyanosis or bradycardia. Providers can use pulse oximetry to monitor trends in O, saturation in response to treatment. If avaiable, contiruously monitor pulse oximetry fora child in respiratory distress or faire during stabiization, transport, and postresuscitation care. Caution in Interpreting Pulse Oximetry Readings Be careful to interpret pulse oximetry readings in conjunc- tion with your cinical assessment and other signs, such as respiratory rate, respiratory effort, and level of conscious- ness. A child may be In respiratory distress yet maintain normal O, Saturation by increasing respiratory rate and effort, especially if supplementary ©, is administered. H the heart rate displayed by the pulse oximeter is not the same as the heart rate determined by ECG monitoring, the O, ‘The O, saturation is the percent of {otal hemogiobin that is saturated with O,. “This saturation dove not indicate the amount of O, delivered to the tissues. O, delivery is the product of artarial O, content (oxygen bound to hemoglobin plus dissolved 0.) and cardiac output. {tis also Important to note that O; saturation does not provide information about effec- tiveness of ventilation (CO, elimination). ‘An O, saturation (Spo,) 284% while @ child is breathing room air usually indicates that | ‘oxygenation is adequate. Consider administration of supplementary O» if the Op satu- ration is below this value in a ori ly ill or injured child. An Spo; of <90% in a child receiving 100% O, is usually an indication for additional intervention.‘saturation reading is not reliable. When the pulse oximeter dows not detect a consistent pulse or there is an irregular ‘or poor waveform, the child may have poor distal pertusion ‘and the pulse oximeter reading may not be accuraie—check the child and intervene as needed. The pulse oximeter may rot be accurate if the child develops severe shock and ‘won't be accurate during cardiac arrest. As noted above, pulse oximetry only indicates O; saturation and does not indicate O, delivery. For example, if the child is profoundly anemic (hemoglobin is very low), the saturation may be 100%, but ©, content in the blood and O, delivery may be low. The pulse oximeter does not accurately recognize met- hemoglobin or cartvoxynemogiobin (hemoglobin bound to carbon monoxide). If carboxyhemoglobin (from carbon ‘monoxide poisoning) is prosont, the pulco oximeter will reflect a falsely high O, saturation. if methemoglobin con- centrations are above 5%. the puise oximeter will read approximately 85% regardless of the degree of methemo- globinemia, If you suspect etther of these conditions, obtain 2 blood gas with O, saturation measurement by using a co-oximeter. Circulation c Circulation is assessed by the evaluation of * Heart rate and rhythm * Pulses (both peripheral anc central) * Capitary rel time * Skin color and temperature + Blood pressure Unne output and level of consciousness also reflect adequacy of circulation. See the Fundamental Fact box “Assessment of Urine Output” at the end of this section, For more information on assessing level of consciousness, ‘see the section “Disability” later in this Par. Heart Rate and Rhythm ‘To determine heart rate, check the pulse rata, listen to the heart, or view a monitor display of the electrocardiogram (ECG) or pulse oximeter wavelorm. The heart rate should ‘be appropriate for the child’s age, level of activity, and clini- cal condition (Table 2). Note that there is a wide range for normal heart rates. For example, a child who is sleeping ‘or is athletic may have a heart rate lower than the normal range for age. ‘Table 2. Normal Heart Rates (por Minute) by Age | Awake Sr) es Go ior Rate Nowborn to | 8510205 | 140 | ato 160 months months te2 | 1000190 | 130 | 75t0 160 years 2yearsto10 | Bto140 | 89 | 60t0.90 years | >iyears | 6010100 | 75 | S0t090 Modifed tron Gilette PC, Garson A J, Craword F Ross B, Ziegler V, Bucklos D. Dysthythmias. I: Adams FH, Emmanouiides GC, Fimenschneider TA, eds. Moss’ Hear Dissese in arts, Crilcren, ana Adolosconts 4th ed, Batimore, MD: Willams & Wiking; 1980:026-020, ‘The heart rhythm is typically regular with only small flic- tuations in rate. When checking the heart rate, assess for abnormalities in the monitored ECG. Cardiac rhythm disturbances (arrhythmias) result from abnormalities in, or incults to, the cardiac conduction system or heart tissue, Arrhythmias also can result from shock ar hypoxia. In the advanced life support setting, an arthythmia in a child can, be broadly classified according to the observed heart rate or effect on perfusion: Coun Ceo Slow Bradycardia Fast Tachycardia Absent Cardiac arrest Bradycardia is a heart rate slower than normal for a child's ‘age. Slight bradycardia may be normal in athletic children, uta very siow rate in a child with other symptoms is @ worrisome sign and may indicate that cardiac arrest is imminent. Hypoxia is the most common cause of brady- cardia in chilcren. Ifa child with bradycardia has signs of oor partusion (decreasad responsiveness, weak peripheral ulses, cool mottled skin), immediately support ventitation with a bag end mask and administer supplementary O.. If the chi with bradycercia is alert and has no signs of poor perfusion, consider other causes of a siow heart rate, such as heart biock or drug overdose. Tachycardia is a resting heart rate that is faster than the normal range for a child's age. Sinus tachycardia is a com- ‘mon, nonspecific response to a variaty of conditions. Itis often appropriate when the child is seriously ill oF injured. To. determine if the tachycardia is a sinus tachycardia or rep- resents a cardiac rhythm disturbance, evaluate the child's, history, clinical condition, and ECG.Systematic Approach to the Seriously Ill or Injured Child Consider the following when evaluating the heart rate and rhythm in any seriously il or injured chité: eae eu cca cy es ‘+ The child's typical heart rate and baseline rhythm *+ The child's level of activity and clinical condition (including baseline cardiac function) Children with congenital heart disease may have conduction abnormalities. Consider the child's baseline ECG when interpreting heart rate and rhythm. Chicren with poor cardiac function are more likely to be symptomatic from arrhythmias than are children with good cardiac function, In healthy children the heart rate may fluctuate with the respiratory cycle, increas- ing with inspiration and siowing down with expiration. This condition is called sinus arrhythmia. Note if the child hs an irregular rhythm that is not related to breathing. An iregular rhythm may indicate an underlying rhythm cisturbance, such as premature ventricular or atrial contractions or an atrioventricular (AV) block Fundamental Fact Relationship of eae Rca Cy For more information, see Part 8: “Recognition and Management of Bradycardia,” Part 9: “Recognition and Management of Tachycardia,” and Part 10: "Recognition, ‘and Management of Cardiac Arrest.” Evaluation of pulses is critica to the assessment of sys- temic perfusion in an ill or injured child. Palpate both cen- tral and peripheral pulses. Central pulses are ordinarily stronger than peripheral pulses because they are present in vessels of larger size that are located closer to the heart. Exeggeration of the difference in quality between central land peripheral pulses occurs when peripheral vasocon- striction is associated with shook. The following pulses ere easily palpable in healthy infants and children (unless the Child is Cbese or the ambient temperature is Cold) Central Pulses + Femoral * Brachial (in infants) * Carotid (in older children) + Axillary © Racial * Dorsalis pedis + Posterior tibia) heat ‘Weak central pulses are worrisome and indicate the need for very rapid intervention to prevent cardiac arrest. beat-to-beat fluctuation in pulse volume may occur in children with arrhythmias (eg, premature atrial or ventricular Contractions}. Fluctuation in pulse volume with the respira- tory cycle (pulsus paradoxus) can occur in children with severe asthma and pericardial tamponade. In an intubated child receiving positive-pressure ventilatory support, a reduction in pulse volume with each positive-pressure breath may indicate hypovolemia. Capillary Refill Time Capillary refil ime is the time it takes for blood to return to tissue blanched by pressure. Capillary refll time increases as skin perfusion decreases. A prolonged capillary refi imo may indicate low cardiac output. Normal capillary refill time: Is <2 seconds, Iti best to evaluate capillary refil in a neutral thermal envi- ronment (ie, oom temperature). To evaluate capillery refill time, lft the extremity slightly above the level of the heart ‘press on the skin, and rapa release the pressure. Note how many seconds it takes for the area to return to its baseline color, {As cardiac output decreases in shock. systemic perfusion decreases incrementally. The decrease in perfusion starts in the extremities with a Gecrease in intensity of Deo ag aed reed pulses and then an absence of peripheral puises. As cardiac output and perfusion decrease further, thore is eventual weakening of central pulses. A cold environment can cause vasoconstriction and a discrepancy between peripheral ‘and central pulses. However, if cardiac output remains adequate, central pulses should remain sirorg,‘Common causes of sluggish, delayed, or prolonged capi lary refill (a refil time >2 seconds) are dehydration, shock, ‘and hypothermia. Note that shock can be present despite ‘@ normal (or even brisk) capilary retil time. Children with warm” septic shock (see Part 6: “Recognition of Shock"), may have excellent (le, <2 seconds} capillary refill time despite the presence of shock. Skin Color and Temperature ‘Monitor changes in skin color, tomporature, and capillary rofl time to assess a child's perfusion and response to therapy. Normal skin color and temperature sould be con- sistent over the trunk and extremities. The mucous mem- branes, nail beds, palms of the hands, and soles of the feet ‘should be pink. When perfusion deteriorates and O; delivery to the tiesues becomes inadequate, the hands and feet are typicelly affected first. They may become cool, pale, dusky, oF mottied, It perfusion becomes worse, the skin over the trunk and extremities may undergo similar changes. Carefully moniter for the following skin findings, which may indicate inadequate O; dalivery to the tissues: + Pator + Motting + Cyanosis Pallor, or paleness, Is a lack of normal cotor jn the skin or mucous membrane. Pallor may be caused by '* Decreased blood supply to the skin (cold, stress, shock, especially hypovolemic end cardiogenic) ‘+ A decteased number of red blood cells (anemia) ++ Decreased skin pigmentation Pallor must be interpreted within the context of other signs and symptoms. It is not necessarily abnormal and ccan result from lack of exposure to sunlight or inherited palenass. Palloris often difficult to detect in a child with dark skin, Thick skin and variation in the vascularity of subcutaneous t'ssue also can make detection of pallor dif- ficut, Family members often can toll you if a child's color is abnormal, Central pallor (e, pale color of the lips and mucous membranes) strongly suggests anemia or poor per- fusion. Pallor of the mucous membranes (the lips, ining of the mouth, tongue, lining of the eyes) an¢ pale palms and soles are more likely to be clinically significant. (Mottling is an irregular or patchy discoloration of the skin, ‘Areas may appear as an uneven combination of pink, bluish gray, or pale skin tones. Mottling may occur due to variax tions in distribution of skin melanin and may be normal. Serious conditions, such as hypoxomia, hypovolemia, or shock, may cause intense vasoconstriction from an irregular supply of oxygenated biood to the skin, leacing to mottiing. Cyanosis is a blue discoloration of the skin end mucous membranes. Blood saturated with O, is bright red, whereas unoxygenated blood is dark bluich-rod. The location of ‘cyanosis is important. Acrocyanosis is a bluish discoloration of the hands and feet. It is a common norma’ finding during the newborn period, Peripheral cyanosis (ie, bluish discoloration of the hands ‘and feat seen beyond the newborn period) can be caused bby diminished O, delivery to the tissues. It may be seen in conditions such as shock, congestive heart failure, or peripheral vascular disease, or conditions causing venous stacis, Central cyanos's is a blue color of the lips and other ‘mucous membranes. Cyanosis is not apparent unti at least § g/dL of hemoglobin are desaturated (not bound to ©,). The O; saturation at which a child will appear cyanotic depends on the child's hemoglobin concentration. For ex- ‘ample, in a child with a hemoglobin concentration of 16 g/dl. ‘cyanosis will appear at an O; saturation of approximately 70% (le, 30% of the hemoglobin, oF 4.8 g/dL, is desatu- rated). If the hemoglobin concentration is low (eg, 8 g/l), a very low arterial O, saturation (eg, <40%) is required to produce cyanosis, Thus, cyanosis may be apparent with a eg tas Consider the temperature of the child's surroundings (ie, ambient temperature) when evaluating skin color and temperature. If the ambiont temperature is cool, poriphoral vasoconstriction may produce mottling or pallor with cool skin and delayed capitary refil, particularly in the extremities, These changes develop despite normal cardiovas- cular function eeu ay acu ie To assess skin temperature, use the back of your hand. The back of the hand is more sensitive to temperature changos than the palm, which has thicker skin. Slide the back of your hand up the extremity to datermine if there is point where the skin changes from cool to warm. Monitor this ine of demarcation between warm and coal skin over time to determine the child's response to therapy. The line should move distally as the child improves.Se ee CR Tey milder degree of hypoxemia in a child with cyanotic con- genital neart cisease and polycythemia (increased amount cf hemoglobin and red blood cel’) but may not be appar- ent despite significant hypoxemia i the child is anemic. The causes of central cyanosis include + Low ambient ©, tension (eg, high attitude) * Alveolar hypoventiiation (eg, traumatic brain injury, drug overdose) * Diffusion defect (eg, pneumonia) * Ventilation/perfusion imbalance (eg, asthma, bronchiol- itis, ARDS) * Intracardiac shunt (eg, cyanotic congenital heart disease) Cyanosis may be more obvious in the mucous membranes and nail beds than in the skin, particulatly if the skin is dark. It also can be seen on the soies of the fest, tip of the nose, and earlobes. As noted above, children with aitferent hemoglobin levels will be cyanotic at different levels of O; ‘saturation; cyanosis is more readily detected at higher O: saturations if the hemoglobin level is high. The development of central cyanosis typically indicates the need for emer- gency intervention, such as Q, administration and ventiia- tory support Blood Pressure Accurate blood pressure measurement requires a prop- erly sized cul. The cuff bladder should cover about 40% of the mid-upper arm circumference. The blood prossure cuff should extend at least 50% to 75% of the length of the upper arm (from the axilla to the antecubital fossa) For more details see The Fourth Report on the Diagncsis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents, 2008 (full reference in the Suggested Reading List at the end of this Part), Normal Blood Pressures ‘Table 3 lists normal blood pressures by age. This table ‘summarizes the range from the 33rd to 67th percentile in the first year of tie and from the 5th to 95th percentile for systolic and diastolic blood pressure according to age ‘and gender and assuming the 50th percentile for height Teas Red for children 21 year of ago. Like heart rate, there is a wide range of values within the normal range. ‘Table 3. Normal Blood Pressures in Children by Age See moet ar ee poor’ a) ) Neonate | 601076 | 601074 | 31t045 | 3010.44 (day) Neonate | 671063 | 681064 | 971059 | 351059 (4 days) Infant 731091 | 741094 | 961056 | 37 1085 (1 month) Infant Tato 100 | 8110 103 | 4064 | 451065 (@ months) Infant 820 102 | 8710 105 | 461066 | 48 1068 (6 months) | Infant 6810 104 | 6710 108 | 2210 60 | 201058 (1 yea) Child 710 105 | 70t0 106 | 2710 65 | 251069 (2years) fo | chia (7 | 7910113 | 7910118 | s9t0 77 | 381078 years) ‘Adolescent | 9310 127 | 05t0 131 | 471085 | 45 1085 (15 years) ‘Blood proseurerangos for nacnate and infat 1 to 6 montha) are from Gemeli i, Mancanaro R, Marri C, De Luca F Longtudinal study of blood pressure durng the 1st your off, Eur J Pec 1990:1493318-320. Blood presaue ranges for infant (1 year child, and adolescent are from National High Blood Pressure Education Program Vioking Group (on High Blood Pressure in Children and Adolescents. The Fourth ‘Report on the Diagnosis, Evaluation, and Treatment of High Blood Pressure #1 Children and Adolescents, Bethesda, MD: National Heat, Lung. and Blood Institute: 2005. NH publication 05-5267,Hypotension Hypotension is defined by the thresholds of systolic blood pressure in Table 4 Table 4. Definition of Hypotension by Systolic Blood Pressure and Age Beers) ae au) Term neonates <60 (0 to 28 days) Infants (1 to 12 months) <70 | Children 1 to 10 years ‘<70 + (age in years = 2) {6th blood prossure percentile) Children >10 years <90 Note that these blood pressure thresholds approximate just above the 5th percentile systolic blood pressures for age, so they will overlap with normal blood pressure values for ‘5% of healthy children, An observed decrease in systolic blood pressure of 10 mm Hg from baseline should prompt serial evaluations for additional signs of shock. In addition, remember that these threshold values were established in normal, resting children. Children with injury and stress typically have increased blood pressure. A blood pressure in the low-normal range may be abnormal in a seriously ilchid, Er ue lia lad ecco Coens et ae es ened Assessment of Urine Ort ‘When hypotension develops in a child with shock, physiologic compensatory mechanisms (eg, tachycardia and vasoconstriction) have failed. Hypotension with hemorrhage is thought to be consistent with an acute joss of 20% to 25% of circulat 1g blood volume. Hypotension may be a sign of septic shock, where there is inappro- priate vasodilation rather than loss of intravascular volume. The development of bradycarcia in a child with tachycardia and hypotension is an ‘ominous sign, Management of airway and breathing and aggressive fluid resuscitation are needed to prevent cardiac arrest. Urine output 's an indirect indication of Kidney perfusion. Children with shock typically have decreased urine output. Measure urine output in all critically ill or injured children with an indwelling catheter. Initial urine output is not a reliable indicator of the child's clinical condition because uch of the urine may have been produced before the onset of symptoms. An increase in urine output is a good indicator of positive response to therapy. Disability D ‘The disability assessmont is a quick evaluation of neuro- logie function. Rapid assessment can use one of several tools to evaluate responsiveness and level of conscious: ress. Perform this evaluation at the end of the primary assessment, Repeat it during the secondary assessment 10 moritor for changes in the chilc’s neurologic status, Clinical signs of brain perfusion are important indicators of circulatory function in the ill or injured pediatric patient, ‘These signs incide level of consciousness, muscle tone, ‘and pupil responses. Signs of inadequate O, delivery to the brain correlate with the severity and duration of cerebral hypoxia, ‘Sudden and severe cerebral hypoxia may present with the folowing neurologic signs: * Docreasod level of consciousness * Loss of muscular tone * Generalized seizures * Pupi dilationSU a er enn ea ee thea ed ‘You may observe other neurologic signs when cerebral hypoxia develops gradually. These signs can be subtle and are best detected with repeated measurements over time: ‘+ Decreased level of consciousness with confusion * Ietapaity * Letnaray * Agitation aternating with letharay ‘Standard evaluations incluce + AVPU (Alert, Responsive to Voice, Responsive to Pain, Urresponsive) Pediatrie Response Seale * Glasgow Coma Scale (GCS) * Pupil response to light AVPU Pediatric Response Scale To rapidly evaluate cerabral cortex function, use the AVPU. Pediatric Response Scale. This scale is a system for rating a child's level of consciousness, an indicator of cerebral cortex function. The scale consists of 4 ratings: Auer The child is awake, active, and ‘appropriately responsive to parents ‘and external stimuli, “Appropriate responea" is assossod in terms of the anticipated response based on the chid's age and the setting or situation. The child responds only to voice (eg, tho child’s name or speaking Voice foul) ‘The child responds only to a paintul ‘stimulus, such as pinching the nail bod, Paintui ‘The child does not respond to any Unresponsive pene | stimulus. Causes of decreased level of consciousness in children include + Poor cerebral perfusion + Traumatic brain injury * Encephalitis, meningitis + Hypoglycemia + Drugs + Hypoxemia + Hypercarbia | an if or injured child has decreased responsiveness, immediately assess oxygen- ation, ventilation, and perfusion. Glasgow Coma Scale Overview The GCS is the most widely used method of evaluating 2 child's level of consciousness and neurologic status, ‘Tho chic's best eye opening (6), verbal (V), and motor (My responses are individually scored (Tebe §). The individual scores are then added together to produce the GCS score, For example: A child who has spontaneous eye opening (E = 4) is fully oriented (V = 5), and is able to follow com- ‘mands (M = 6) is assigned a GCS score of 15, the highest possible score. A child with no oye opening (E = 1), no verbal response (V = 1), and no motor response (M = 1) to 4 painful stimulus is assigned a GCS score of 3, the lowest possible score, ‘Severity of head injury is categorized into 3 levels based on GCS score alter intial resuscitation: + Mild head injury: GCS score 13 to 15 + Moderate head injury: GCS score 9 to 12 + Severe head injury: GCS score 3 to 8 Glasgow Coma Scale Scoring ‘The GOS has been moditied for preverbal or nonverbal ‘children (Table 5}. Scores for eye opening are essentially the ‘same as for the standard GCS. The best motor response ‘score (of a possible 6 requires that a child fotow com- ‘mands, so this section was adapted to accommodate the preverbal or nonverbal child. The verbal score wes also adapted to assess age-appropriate responses. ‘Important: When using the GCS cr its pediatric modifioa- tion, record the individual components of the score. if the Patient is intubated, unconscious, or preverbal, the most important part of this scale is motor response, Providers should carefully evaluate this component.