P ediatric A dvanced L ife S upport By R2 張家穎. 小兒生命之鏈 預防措施 早期 CPR 早期求救 高級小兒 救命術.

Pediatric Advanced Life Support By R2 張家穎

小兒生命之鏈

預防措施 早期 CPR 早期求救

高級小兒救命術

Basic Life SupportBasic Life Support

• Pediatric assessment triangle

Appearance, Breathing, Circulation• Airway

Breathing

Circulation

D: disability, differential diagnosis

Exposure.

AppearanceBC

• Tone

• Interactiveness

• Consolability

• Look/Gaze

• Speech/Cry

　　 TICLS

ABreathingC• Nasal flaring.• 胸凹• 點頭式呼吸• Use of accessory mus

cles.

　 AGE 　 RR

Neonate 　 40~60

Infant 　 30~60

Toddler 　 25~40

Schooler 　 20~30

Adolescent 　 12~18

ABCirculation

• Pink

• Pale

• Mottling skin.

• Cyanosis.

• Capillary refill time: normal <2 sec.

• DBP: 70+ age *2

　 AGE 　 HR 　 BP

Pre-

maturity

DBP~

Gestational age

Neonate 80~200 SBP 50~90

1~10 y/o 100~180 DBP:

70+age*2

>10 y/o 60~140 SBP>90Ｃ apillary refill time:

Normal : <2 sec.

ABCDE

2nd assessment

AirwayBCDE

• 建立呼吸道• Nasal airway. Oral airway.

• Endotracheal tube:

size: 4+ age/4. 比較小朋友的小指頭　　 depth: 12+ age/2. or endo size *3.

B.W.(Kg)+6

• LMA

ABreathingCDE

• Adequate ventilation.

• Indications for endotracheal tube insertion:

Fail to keep patent airway.

Respiratory failure

Severe shock

GCS< 9

IICP

ABCirculationDE~1• Chest compression. (HR<60)

> 8 y/o <8 y/o Newborn

Check pulse Common carotid a.

Common carotid a.

Brachial a.

Umbilical a.

Position 胸骨下半段 胸骨下半段 兩乳頭連線下一指幅

Method 兩手指互扣 單手掌跟 兩手指兩手環抱 , 以拇指壓

Depth 4~5 cm 胸壁厚度 1/2~1/3

胸壁厚度 1/2~1/3

Ratio 15:2 5:1=100:20 3:1=90:30

ABCirculationDE~2

• HR: fast, slow, asystole• Fast: Stable Unstable narrow: drug: adenosin: 0.1 　 0.2 　 0.2 mg/Kg shock: synchronized shock: 0.5 　 1 J/Kg. wide: synchronized shock: 0.5 　 1 J/Kg.• Slow: HR<60, 常因缺氧 , 低血壓或是酸血症所引起 . 　先弄好 ventilation/oxygenation Chest compression Bosmin use: 0.1 mg/Kg via endo. 0.01 mg/Kg via IV.• Pulse(-): VT/VF: unsynchronized shock: 2 　 4 　 4J/Kg. PEA: 4H4T

CCB is contraindicated!!!

電 電 電 藥 電 藥 電　

xylocaine: 1mg/kg. amiodarone 5mg/kg.

ABCirculationDE~3

• Fluid bolus: 10~20 ml/Kg NS or LR

• Transfusion: after 3 times of fluid challenge. 10~15 ml/Kg.

• Inotropics use: Dopamine

Dobutrex

Primacor

Levephed

ABCDisabilityE

• AVPU: Alert Voice Pain Unresponsive• Protect brain- Keep vital signs stable first. 　　　　　　　 Avoid hypotension. hyperglycemia. hyperthermia.• 連續發作超過三十分鐘 , 而沒有恢復意識 , 即稱為癲間重積狀態 , mortality 達 10~15%.

ABCDExposure

ＤＯＰＥ

• D: Displacement

• O: Obstruction.

• P: pneumothorax.

• E: equipment failure.

Vascular acess.

Newborn management

• Oral suction.• 擦乾擺位 .• PAT observation.• O2 supply and stimulation( 摩擦背部 ,按摩腳底 ).

• Positive pressure ventilation.• Chest compression. 3:1=90:30.• Endotracheal tube insertion.• On Umbilical vein and giving medication.

If meconium presents?

Trauma

• Usually multiple organ trauma.

FAST- subxiphoid, subcostal, suprapubic

• Pneumothorax, hemothorax, pulmonary contussion.

• Permissive hypotension. • Blood product transfusion:

PRBC: 10~15 ml/kg.

PLT: 10~15 ml/kg. if plt<50,000.

FFP: 10~15 ml/kg, if INR>1.5*.

Cryo: 10~15 ml/kg, if fibrinogen <0.8 g/l• Adequate urine output:

Infant: 2ml/kg/hr.

child: 1.5 ml/kg/hr.

adolescent: 0.5 ml/kg/hr.

~The End~

Thanks for your attension.