American AMERICAN Heart ‘ASSOCIATION Associations ‘CRITICAL-CARE _ NURSES life is why~ PALS Vital Signs in Children Normal Respiratory Rates Normal Heart Rates* (beats/min) (breaths/min) Age Awake Rate Sleeping Rate | Age Rate Neonate 100-205 90-160 Infant 30-53 Infant 100-180 90-160 Toddler 22-37 Toddler 98-140 80-120 Preschooler 20-28 Preschooler 80-120 65-100 School-aged child 18-25 School-aged child 75-118 58-90 Adolescent 12-20 Adolescent 60-100 50-90 Normal Blood Pressures Systolic Diastolic Mean Arterial Age Pressure Pressure Pressure (mm Hg)t (mm Hg)t (mm Hg)! Birth (12 h, <1000 g) 39-59 16-36 28-428 Birth (12 h, 3 kg) 60-76 31-45 48-57 Neonate (96 h) 67-84 35-53 45-60 Infant (1-12 mo) 72-104 37-56 50-62 Toddler (1-2 y) 86-106 42-63 49-62 Preschooler (3-5 y) 89-112 46-72 58-69 School-aged child (6-7 y) 97-115 $7-76 66-72 Preadolescent (10-12 y) 102-120 61-80 71-79 Adolescent (12-15 y) 110-131 64-83 73-84 “Always consider the patient's normal range and clinical condition. Heart rate will normally increase with fever or stress. Systolic and diastolic blood pressure ranges assume 50th percentile for height for children 1 year and older. +Mean arterial pressures (diastolic pressure + (difference between systolic and diastolic pressure/3)) for 1 year and older, assuming 50th percentile for height. Approximately equal to postconception age in weeks (may add 5 mm Ha). Reproduced from Hazinski MF. Children are different. In: Hazinski MF, ed. Nursing Care of the Critically ll Child. rd ed. St Louis, MO: Mosby; 2013:1-18, copyright Elsevier. Data from Gemelli M, Manganaro R, Mami C, De Luca F. Longitudinal study of blood pressure during the 1st year of life. Eur J Pediatr. 1990;1495):318-320; ‘Versmold HT, Kitterman JA, Phibbs RH, Gregory GA, Tooley WH. Aortic blood pressure during the first 12 hours of life in infants with birth weight 610 to 4,220 grams. Pediatrics. 1981;67(5):607-613; Haque IU, Zaritsky AL, Analysis af the evidence for the lower limit of systolic and mean arterial pressure in children. Peaiatr Crit Care (Med. 2007;8(2):138-144: and National High Blood Pressure Education Program Working Group on High Blood Pressure in Children and Adolescents. The Fourth Report on the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents. Bethesda, MD: National Heart, Lung, and Blood Institute; 2005, NIH publication 05-5267. 15-1046 10/16 | © 2016 American Heart Association ISBN 978-1-61669-560-6 Printed in the USA,uossiuued ys poquudey ‘Auediiog pue Losuniaig ‘uo}Ieg © pur Asaynog ‘ou) suBig (e3/A 2002 1UBUAdOD “) ‘auIYSUjOOUIT ‘oul SeL|SNpU) jeoIPEYy BUOASUUY Aq parnquasiG ‘ede, ADLABIeW IUReIPEY W,mojesolg Woy pardepy ‘(Pied siuq 40 @pIs O840n01 BUR LO 9zIg eqn|, eeYoeACPUT BuloWNsy eas) pasn eq ABW seq PeynauN 40 Paynd jeydsoy ayp UI ‘SOUI]EPIND WHY 010Z 18d, PAIS! 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PIUOAUER — PINOAUEIHL x 7s D uoneyosnseyy -—s a9 [at 4Pediatric Cardiac Arrest Algorithm—2015 Update Start CPR * Give oxygen Asystole/PEA CPR 2 min * IO/IV access CPR 2 min * IO/IV access * Epinephrine every 3-5 min * Consider advanced airway CPR 2 min * Epinephrine every 3-5 min * Consider advanced airway CPR 2 min ° Treat reversible causes CPR 2 min * Amiodarone or lidocaine * Treat reversible causes * Asystole/PEA > 10 or 11 * Organized rhythm > check pulse * Pulse present (ROSC) — post—cardiac arrest careDoses/Details for the Pediatric Cardiac Arrest Algorithm CPR Quality * Push hard (2% of anteroposterior diameter of chest) and fast (400-120/min) and allow complete chest recoil. Minimize interruptions in compressions. * Avoid excessive ventilation. Rotate compressor every 2 minutes, or sooner if fatigued. If no advanced airway, 15:2 compression-ventilation ratio. Shock Energy for Defibrillation First shock 2 J/kg, second shock 4 J/kg, subsequent shocks 24 J/kg, Advanced Airway ¢ Endotracheal intubation or supraglottic advanced alrway * Waveform capnography or capnometry to confirm and monitor ET tube placement * Once advanced airway in place, give 1 breath every 6 seconds (10 breaths/min) with continuous chest compressions Return of Spontaneous Circulation (ROSC) ¢ Pulse and blood pressure * Spontaneous arterial pressure waves with intra-arterial monitoring maximum 10 J/kg or adult dose SRR Drug Therapy Epinephrine I0/IV dose: Hypovolemia Hypoxia 0.01 mg/kg (0.1 mL/kg of the Hydrogen ion (acidosis) 0.1mg/mL concentration). Repeat Hypoglycemia every 3-5 minutes. If no !O/IV Hypo-/hyperkalemia access, may give endotracheal Hypothermia dose: 0.1 mg/kg (0.1 mL/kg of the 1 mg/mL concentration). Amiodarone I0/IV dose: 5 mg/kg bolus during cardiac arrest. May repeat up to 2 times for refractory VF/pulseless VT. Lidocaine IO/IV dose: Initial: 1 mg/kg loading dose. Maintenance: 20-50 mcg/kg per minute infusion (repeat bolus dose if infusion initiated >15 minutes after initial bolus therapy). Tension pneumothorax Tamponade, cardiac Toxins Thrombosis, pulmonary Thrombosis, coronary ee eoer ere ceo e Estimating Endotracheal Tube Size The formula for estimation of proper endotracheal tube size (internal diameter [i.d.]) for children 2 to 10 years of age, based on the child’s age: Uncuffed endotracheal tube size (mm i.d.) = (age in years/4) + 4 The formula for estimation of a cuffed endotracheal tube size is as follows: Cuffed endotracheal tube size (mm i.d.) = (age in years/4) + 3.5 Typical cuffed inflation pressure should be <20 to 25 cm H,O.PALS Systematic Approach Algorithm Initial impression (appearance, breathing, circulation) Is child unresponsive or is immediate intervention needed? a_i | Shout for help. | Activate emergency response plan (as appropriate for setting). No breathi or only gasping, no pulse Does child have severe compromise of No breathing, but pulse present Open and maintain airway. Begin ventilation. | Provide oxygen when available. | Attach monitor, pulse oximeter. { Support airway, ventilation, | | and perfusion. Provide oxygen as needed. Attach monitor, pulse oximeter. ibm Is pulse <60/min with poor perfusion despite If at any time you identify cardiac arrest Evaluate * Primary assessment * Secondary assessment © Diagnostic assessments Start CPR (C-A-B). Intervene \ Pediatric Cardiac Arrest Algorithm. After ROSC, provide post-cardiac arrest care. Begin | evaluate-identify-intervene sequence. Nae DPediatric Bradycardia With a Pulse and Poor Perfusion Algorithm Identify and treat underlying cause * Maintain patent airway; assist breathing as necessary * Oxygen * Cardiac monitor to identify rhythm; monitor blood pressure and oximetry | * IO/V access | + 12-Lead ECG if available; don't delay therapy Cardiopulmonary compromise? ° Hypotension © Acutely altered mental No CPR if HR <60/min with poor perfusion despite nation and ventilation © Support ABCs | © Give oxygen Doses/Details | is Observe Epinephrine l0/IV | * Consider expert dose: 0.01 mg/k: consultation NT RLnG oe: — (0.1 mL/kg of the ee 0.1 mg/mL concentra- - tion). Repeat every | | 3-5 minutes. If IO/IV | access not available but endotracheal (ET) tube in place, may give ET dose: * Epinephrine * Atropine for increased vagal tone or primary AV block * Gonsider transthoracic pacing/ transvenous pacing | | * Treat underlying causes | 0.1 mg/kg (0.1 mL/kg of the 1 mg/mL concentration). Atropine 10/IV dose: 0.02 mg/kg. May If pulseless arrest repeat once. Minimum develops, go to Cardiac dose 0.1 mg and Arrest Algorithm maximum single dose 0.5 mg.PALS Management of Shock After ROSC Algorithm Optimize Ventilation and Oxygenation © Titrate Fi0, to maintain oxyhemoglobin saturation 94%-99% (or as appropriate to the patient’s condition); if possible, wean Fi0, if saturation is 100%. * Consider advanced airway placement and waveform capnography. © If possible, target a PCO, that is appropriate for the patient's condition and limit exposure to severe hypercapnia or hypocapnia. "Assess for and *Possible Treat Persistent Contributing Factors | Shock Hypovolemia * Identify and treat Hypoxia contributing factors* Hydrogen ion (acidosis) * Consider 20 mL/kg Hypoglycemia IVAO boluses of Hypo-/hyperkalemia isotonic crystalloid. Hypothermia Consider smaller boluses (eg, 10 mL/kg) if poor cardiac function suspected. * Considertheneed | for inotropic and/or vasopressor support — for fluid-refractory shock. Tension pneumothorax Tamponade, cardiac Toxins Thrombosis, pulmonary Thrombosis, coronary Trauma Hypotensive Shock * Epinephrine * Dopamine * Norepinephrine | Normotensive Shock * Dobutamine * Dopamine * Epinephrine * Milrinone a, * Monitor for and treat agitation and seizures. * Monitor for and treat hypoglycemia. * Assess blood gas, serum electrolytes, and calcium. « If patient remains comatose after resuscitation from cardiac arrest, maintain targeted temperature management, including aggressive treatment of fever. * Consider consultation and patient transport to tertiary care center, | Estimation of Maintenance Fluid Requirements © Infants <10 kg: 4 mL/kg per hour Example: For an 8-kg infant, estimated maintenance fluid rate = 4mL/kg per hour x 8 kg = 82 mL per hour Children 10-20 kg: 40 mL per hour + 2 mL/kg per hour for each kg above 10 kg Example: For a 15-kg child, estimated maintenance fluid rate 40 mL per hour + (2 mL/kg per hour x 5 kg) = 50 mL per hour * Children >20 kg: 60 mL per hour + 1 mL/kg per hour for each kg above 20 kg Example: For a 28-kg child, estimated maintenance fluid rate 60 mL per hour + (1 mL/kg per hour x 8 kg) =68 mL per hour After initial stabilization, adjust the rate and composition of intravenous fluids based on the patient's clinical condition and state of hydration. In general, provide a continu- ous infusion of a dextrose- containing solution for infants. Avoid hypotonic solutions in Critically ill children; for most Patients, use isotonic fiuid such as normal saline (0.9% NaCl) or lactated Ringer’s solution with or without dextrose, based on the child’s clinical status.ete ca (eM ey Certara) Elite elem eam Wel alli Doses/Details Identity and treat underlying cause * Maintain patent airway; assist breathing as Meee] necessary ere el * Oxygen * Cardiac monitor to identify rhythm; monitor blood | Begin with 0.5- pressure and oximetry 1 1 J/kg; if not * IO/V access | effective, * 12-Lead ECG jf available; don’t delay therapy | increase to 2 J/kg. Sedate Narrow Wide itneedied, but don't delay {<0.09 sec) ae {>0.09 sec) cardioversion. QRS duration Evaluate rhythm with 12-lead ECG Adenosine or monitor 1O/IV dose: ee First dose: 0.1 mg/kg rapid — ., ES bolus (maximum: Probable Probable i Possible 6 mg). sinus supraventricular ventricular ‘Second dose: tachycardia tachycardia —_—|_ tachycardia 0.2 mg/kg rapid | © Compatible * Compatible | \aeiepameeeess co bolus (maximum | history history (vague, | are Coe consistent with nonspecific); i i | known cause history of abrupt | prmcdarone | i IOAV dose: * P waves rate changes | 5 mg/kg over present/normal * P waves absent/ 20-80 minutes * Variable R-R; abnormal or constant PR « HR notvariable | Procainamide © Infants: Infants: rate | IO/IV dose: rate usually usually 2220/min Cardiopulmonary 15 mg/kg over <220/min * Children: rate t compromise? 30-60 minutes + usually2180/min / = Hypotension Do not routinely * Children: rate ; * Acutely altered administer usually <180/min ; mental status amiodarone and y y procainamide | together. ( ‘Search for ) Consider | | ( ; i } | | Synchronized | Consider | | and vagal cardioversion || adenosine | | treat cause maneuvers — \ J if rhythm regular | (No delays) | and QRS monomorphic ¢ Sema C >) | © If lO/V access present, give adenosine | Expert | or | consultation | © If IO/V access not available, or if adenosine advised ineffective, synchronized cardioversion * Amiodarone * Procainamide Cece icete ca (eM ey Certara) Elite elem eam Wel alli Doses/Details Identity and treat underlying cause * Maintain patent airway; assist breathing as Meee] necessary ere el * Oxygen * Cardiac monitor to identify rhythm; monitor blood | Begin with 0.5- pressure and oximetry 1 1 J/kg; if not * IO/V access | effective, * 12-Lead ECG jf available; don’t delay therapy | increase to 2 J/kg. Sedate Narrow Wide itneedied, but don't delay {<0.09 sec) ae {>0.09 sec) cardioversion. QRS duration Evaluate rhythm with 12-lead ECG Adenosine or monitor 1O/IV dose: ee First dose: 0.1 mg/kg rapid — ., ES bolus (maximum: Probable Probable i Possible 6 mg). sinus supraventricular ventricular ‘Second dose: tachycardia tachycardia —_—|_ tachycardia 0.2 mg/kg rapid | © Compatible * Compatible | \aeiepameeeess co bolus (maximum | history history (vague, | are Coe consistent with nonspecific); i i | known cause history of abrupt | prmcdarone | i IOAV dose: * P waves rate changes | 5 mg/kg over present/normal * P waves absent/ 20-80 minutes * Variable R-R; abnormal or constant PR « HR notvariable | Procainamide © Infants: Infants: rate | IO/IV dose: rate usually usually 2220/min Cardiopulmonary 15 mg/kg over <220/min * Children: rate t compromise? 30-60 minutes + usually2180/min / = Hypotension Do not routinely * Children: rate ; * Acutely altered administer usually <180/min ; mental status amiodarone and y y procainamide | together. ( ‘Search for ) Consider | | ( ; i } | | Synchronized | Consider | | and vagal cardioversion || adenosine | | treat cause maneuvers — \ J if rhythm regular | (No delays) | and QRS monomorphic ¢ Sema C >) | © If lO/V access present, give adenosine | Expert | or | consultation | © If IO/V access not available, or if adenosine advised ineffective, synchronized cardioversion * Amiodarone * Procainamide Cece icPediatric Septic Shock Algorithm Be Cre es le ree) Initial stabilization cr Identity Signs of Septic Shook {as below or per protocol) * Altered mental status (irtabilty or decreased level of consciousness) Altered heart rate (tachycardia or, less commonly, bradycardia) * Altered temperature {fever or hypothermia) + Altered perfusion (prolonged or “flash” capillary refll; cool or vory warm extremities; plethorie appearance, mottled color or pallor; possible ecchymosis or purpura; decreased urine output) ‘+ Hypotension: May or may not be present | Immediate (10-15 min) Initia! Stabilization Monitor and suppor airway, breathing, and circulation | + Monitor heart rae, blood pressure, and pulse oximetry | + Esicblish vasculer access (Vor 10}; draw blood for culture and |” adaitional taooratory studios, including glucose and eacum—do rot | Gelay antibiotic or fic therapy | | | * Antibiotics: Give broad-spectrum antibiotics + Fluid boluses: Give 20 m./g isotonic crystaloid boluses (10 mLikg for neonates and those with pre-existing cardiovascular compromise). Assess carefuly after each bolus. Repeat as needed to treat shock. Stop ff rales, respiratory distress, or hepatomenaly develops, | + Give antipyretics if needed | Goals of therapy: Improved mental status, normalization of heart | tate and temperature, adequste systolic and diastolic bloed pressure | Improved perfusion (see.box above) First hour’ Consider critical ccare consultation ‘* Obtain expert/enitical care consultation * Initiate and titrate vasoactive drugs: } = Cold extremities, delayed capillary refil, and/or low blood pressure: Epinephrine (use dopamine if epinephrine is not available) ~ Warm extremities, “flash” capillary refil, and/or low (typically diastolic) blood pressure: Norepinephrine (Use higher dose of dopamine if norepinephrine is not available) ‘Therapies intendad forthe critical care environment and expertise { + Establish central venous and intra-arterial pressure monitoring * Continue epinephrine/norepinephrine (as above) and bolus fluid therapy as needed to treat shock * Verity adequate airway, oxygenation, and ventlation * Evaluate cortisol if at risk for relative adrenal ingufficiency; consider atross dose hydrocortisone Critical care goals of therapy: Scv0, >70%, adequate BR normalized HR, adequate cardiac output/index and organ perfusion y Sov0,<70% Sev0,270% Scv0,270% with poor With poor pertusion Signs of perfusion and ‘and warm shock cold extremities extremities despite resolved despite | norepinephrine epinephrine ‘administration administration t Y y | gee oua | | eee sine es | ees ae ee: see | ee + Support organ function Goals of care: Improved Sevo,, normalized HF and BP, adequate cardiac outpuvindex ana organ perfusion rnotmalized HR and BP adequate cardiac output/index and ‘organ perfusionDrugs Used in PALS Drugs Used in PALS (continued) cone et W mtahrs r om 02 aa 0 en mote MO tom 388 et ont saree Seneimrnte pean nal ht wes cee pea Tras | Rt ner PaRLD ens eee a eaten ‘mpg tee ab verona lassen Sige ou ae EEE” [S27 sone uinanaat nna astom » Nt wos toh anon gh a : : Teams | 0 fe re Tze | ann or woes one PS Asso mmr mp meh ee ee cnas a * peter SR ase CSE any etna ant tetas = So tine ea a A ‘Atropine suttote | Bradyeardia (symptomatic) a near yous ane nainsninan | [amor | Sarastieten inert kimeet ares smear 1d mt VAG fax sce dour ay eon don * Bras aie ofS Sorta fas cane «Suissa ; ag ie et eat eect uve aman cm om | SE Seana Bee a ETE CERT eT sane sonny | [omni | rev anumatgcrber aa ML Ecc at a ate nee svi | [TOR er itn reg BT TEL ces eee AME as y0250 TEE [Reesor merits peopana ae Sorina oa = _ Socios {trot sinaran soak arouse RTE en aya m6 rota Cas, | igen nami reper ee at ore Wraith eet eg ioe | Memeo uN ee ee OT eel tet and st Sows Ser teh ese hones arte a cia sateS wg rsa 5 : * Taian ein een er Cie W5 to 10 ming ++ Initlate at 0.25 to 0.6 megikg per minute IVAO infusion; titrate by + x9 per ieawcen e892 BG NOD B15 STNG CONE 2 ‘minute q 15 to 20 miwtes as tolerated, Typical dose range 1 to 5 megikg per Desa [fe hr cere eee eae sone [SPORES SRE won ee » Eee SPA its nm tp oan rr ‘Dopamine | Cariogonte shook, dstbutve shock eee 0 SEEREISL EST amma: | ira Sse os cee LR TRIN ‘cna Per rors rat oe sre oe Migearw Meters SR wna 0 ea ran Toso [gees ey Sebi ck ne act (macangl one m0) ait 8 tia2 mega pet mate No soo tee to ees tect ESSE Sm nomtsoorenoteTestsniue | petetnce mre pees S'S mg WA load ve Sb 80 nun (ont wee etn wth amidaon ee mmo van ce ee SSL IO Be ~ se | Di err npn x as [tc os eget eg 30.9e ier asonecorossma) [BSE | Poaeratssos eae en ta bao 08 neha Sette S SES Prom stn aa smn sma — pecan ean ne ans ao Sage het es gp orensev0 4 Snt = i pec atne Se es a rn vet aera ERR BRAN en ange dp SERS ee eT nen ipigereer ese ee nt aclyiao card areas mas ro son — Terbutaline | ‘Asthma (status asthmatious), hyperkalemia * CO gO 01 otg oe gf comer) aan 1 nen SD to fe mopkg porate NO nk consider 10 meat MO lad ovr eee ee Se cers snc scr 22 raesn 3m na man «Eee cement toot wo nor Fee ec vx wa SOLES A tnsatomeimiura ae a re Can fo 0.00 una po mint 2 to 2 mires pet mit) contnuous inion