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New guidelines for pediatric advanced life support (PALS) from the Dallas-based American Heart Association (AHA) will have a major impact on the way you treat critically ill infants and children, stresses Michele Wolff, RN, MSN, CCRN, professor of nursing at Saddleback College in Mission Viejo, CA. Here, Wolff presents hypothetical "before" and "after" scenarios that illustrate how your practice should change.
Here’s how a critically ill child might have been cared for before the new PALS guidelines were published:
A 10-year-old child was found floating facedown in a wave pool at a water park. Cardiopulmonary resuscitation (CPR) was begun by one of the water park employees. When the paramedics arrived, she was found to be pulseless and apneic with a ventricular fibrillation rhythm. She was successfully defibrillated on the third attempt using 4 J/kg of a standard defibrillator. She was intubated and hyperventilated during transport. Visual cues (chest rise, vapor in the tube, breath sounds) were used to confirm proper placement. Several attempts were made at IV access before a small butterfly needle was placed in her right hand.
Upon arrival to the ED, the child was placed under heat lamps to treat her hypothermia. Shortly after arrival, the child converted back to a ventricular fibrillation rhythm. During multiple attempts to defibrillate, standard-dose epinephrine, high-dose epinephrine, and lidocaine were administered. When the child’s parents arrived, they were told that their daughter was critically ill and to wait for more information in the family conference room. They sat alone in a conference room crying during the resuscitation.
Here’s how this case would be managed utilizing recommendations from the new guidelines:
A 10-year-old child was found floating facedown in a wave pool at a water park. She was transported and admitted to the ED. CPR was begun by one of the water park employees. Another employee trained in the use of automatic external defibrillators (AEDs) obtained the water park’s biphasic AED and placed it on the child. The AED identified a ventricular fibrillation rhythm. The water park employee followed the AED audio prompts and delivered two shocks. After the second shock, the AED advised the bystanders to continue CPR and no additional shocks were advised. When the paramedics arrived, the child had weak pulses with a bradycardic rhythm. The paramedics began ventilation at a normal rate using a resuscitation bag and the E-C clamp technique. The child’s heart rate increased to sinus tachycardia after the airway was established. An intraosseous needle was placed when initial attempts at peripheral vascular access were unsuccessful.
Upon arrival to the ED, a tracheal tube was placed. An exhaled CO2 colorimetric devise confirming the presence of CO2 was used in addition to visual cues for tube placement confirmation. Although the child was mildly hypothermic, she was not actively rewarmed. Shortly after arrival, the child converted back to a ventricular fibrillation rhythm. During attempts to defibrillate, standard-dose epinephrine and amiodarone were administered. When the child’s parents arrived, they were told that their daughter was critically ill and that they could be present at the bedside during resuscitation. They were escorted to their daughter’s bedside during resuscitation. One of the nurses took on the role of designated support person to stay with the parents while providing ongoing support and information.