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Pals update taiwan2015
- 1. Liu Yueh-Ping ,M.D. Department of Emergency Medicine ,NTUH 1
- 3. 3
- 4. PALS training is more important for HCP 4
- 5. Pediatric Cardiac Arrest: state of the art Survival to discharge from out-of-hospital pediatric cardiac arrest (PCA) has not changed in 20 years remains at 6% 3% for infants 9% for children and adolescents 5
- 6. Poor outcomes of pediatric traumatic arrest Examined cohort of 118 children <13 years of age found pulseless and apneic after an injury 6 (5%) survived Median ISS was 25 All survivors were neurologically impaired with pediatric cerebral performance category of 5 Brindis, SL et al PEC 2011 6
- 7. Pediatric out of hospital cardiac arrest EMS systems and healthcare providers should identify and strengthen “weak links” in the chain of survival Topjian and Berg Circulation 2012 Field et al Circulation 2010 7
- 8. In-hospital PCA: state of the art Survival from in-house cardiac arrest in infants and children has improved significantly 1980s: 9% 2000s: 17% 2006: 27% 8
- 9. What changed in the hospital Earlier recognition of clinical deterioration More aggressive implementation of resuscitation guidelines Implementation of formal rapid response teams (RRT) or medical emergency teams (MET) Decreased number of cardiac arrests and respiratory arrests by as much as 72% Decreased hospital mortality by 35% 9
- 11. 11 PEDIATRIC ADVANCED LIFE SUPPORT 2015 American Heart Association Guidelines for Cardiopulmonary Resuscitation (CPR) and Emergency Cardiovascular Care (ECC)
- 13. AHA Image/Graphic Needed Here - Image of team resuscitation Part 11: PBLS & CPR Quality Part 12: Pediatric ALS Part 13: Neonatal Resuscitation Science updates to CPR and ECC
- 14. Learn and Live Chain of Survival
- 15. PEDIATRIC BASIC LIFE SUPPORT 2015 American Heart Association Guidelines for Cardiopulmonary Resuscitation (CPR) and Emergency Cardiovascular Care (ECC)
- 16. Key Issues in Pediatric Life Support • 再度肯定 C-A-B 步驟適用於小兒 CPR 步驟 • 順應手機盛行，適用於 1 位施救者和多位施救者的小兒 HCP CPR 新流程 • 規定青少年的胸部按壓深度上限為 6 cm • 反映成人 BLS 所建議的胸部按壓速率為 100 至 120 次/分鐘 • 再度強烈肯定小兒 BLS 必須包含按壓和通氣
- 17. 適用於 1 位施救者和多位施救者的 HCP CPR 新流程 順應有揚聲器的手機盛行，將適用於 1 位施救者和多 位施救者的 HCP 小兒 CPR 流程分開 ( 圖 7 和圖 8)， 以利引導施救者順利完成復甦的初步階段。
- 18. Gasping = not breathing Pulse check <10 sec One rescuer 30:2 Two rescuers 15:2
- 22. Infants Children GUIDELINE Compression Depth Recommendation 1 ½ inches or 4 cm 2 inches or 5 cm 至於已屆青春期的兒童 ( 也就是青少年)，成人的建議按壓深度為至少 2 英吋 (5 cm) 但不得超過 2.4 英吋 (6 cm)。
- 24. 24
- 25. 單純按壓 CPR 由於單純按壓 CPR 可有效救治原發性心臟停止病患，若 施救者不願意或無法進行人工呼吸，建議可為心臟停止的 嬰兒和兒童進行單純按壓 CPR。
- 26. 26 PEDIATRIC ADVANCED LIFE SUPPORT 2015 American Heart Association Guidelines for Cardiopulmonary Resuscitation (CPR) and Emergency Cardiovascular Care (ECC)
- 27. 27 Key Issues in Pediatric Advanced Life Support • 輸液補充建議 • Atropine 與氣管插管 • 電擊頑固性心室顫動或無脈搏性心室心搏過速的抗心律不整藥物 • 血管升壓劑與復甦 • 目標體溫管理 • 復甦後的 PaO2 及 PaCO2
- 28. GUIDELINE 輸液補充建議 在早期，等張液體快速 IV 給藥公認為敗血性休克的治 療基礎。最近一項大型隨機對照輸液補充試驗，納入資 源有限情況下的嚴重發熱疾病病童，試驗結果發現接受 IV 推注病患的預後較差。 休克的兒童初次推注20 mL/kg 應是適當的做法。 不過在可用的重症照護資源( 亦即機械性通氣和強心劑) 有限時，為患有發熱疾病的兒童快速推注 IV 輸液必須 特別注意，因為可能造成傷害。 應強調個人化治療，並經常進行臨床重新評估。
- 29. GUIDELINE Atropine 與氣管插管 並無證據支持例行使用 Atropine 做為前驅用藥，可 預防小兒緊急插管時發生心搏過緩，但在心搏過緩風 險增加的情況下，可考慮使用。 並無證據支持以Atropine 做為緊急插管前驅用藥時， 可使用的最小劑量( 0.1 mg IV)。
- 30. 30 Amiodarone 或 Lidocaine，同樣可用 來治療兒童之電擊頑 固性心室顫動或無脈 搏性心室心搏過速。 仍然建議小兒心臟停止時， 使用 Epinephrine 做為 血管升壓劑。
- 31. GUIDELINE 目標體溫管理 對於心臟停止 ( 在院內或到院前) 後前幾天昏迷的兒 童，應持續監測體溫並積極治療發燒的問題。 對於自 OHCA 復甦的昏迷兒童，維持 5 天體溫正常 (36 °C 到 37.5 °C)，或最初 2 天持續維持低體溫 (32 °C到 34 °C)，接著 3 天保持體溫正常，都是適 當的做法。 對於 IHCA 後仍昏迷的兒童，目前的資料不足以提出 保持低體溫優於體溫正常的建議。
- 32. GUIDELINE Resuscitation of Infants and Children with Congenital Heart Disease 如果有適當的流程、專業知識技術和設 備，對於患有心臟疾病且發生 IHCA 的兒童， 可考慮使用ECPR。
- 33. Consider Therapeutic Hypothermia 32oC – 34oC GUIDELINE Post-Cardiac Arrest Care
- 34. 復甦後的 PaO2 及 PaCO2 在兒童 ROSC 後，施救者應可合理調整給予的氧氣， 以達到正常血氧 ( 氧合血紅素飽和度達 94%以上)。 有必要設備可用時應減少給氧，使氧合血紅素飽和度維 持在 94% 到 99% 之間。 在維持正常血氧的同時，應以絕對避免血氧過少為目 標。 兒童的 ROSC 後通氣策略，應以達到適合病患狀況， 且能避免發生嚴重高血碳酸或低血碳酸的 PaCO2 為目 標。
- 35. Newborn Resuscitation Assess baby’s response to birth Initial steps Establish effective ventilation •Bag and mask •Endotracheal intubation Provide chest compressions Administer medications Always needed by newborns Needed less frequently Rarely needed by newborns
- 36. 36 評估心率使用 3 導極 ECG 低於 35 週妊娠的早產新生 兒復甦，應該從低氧氣濃度 (21% 到 30%)開始
- 37. 新生兒復甦 3 個評估問題的順序變更為 (1) 足月？ (2) 肌張力 良好？以及 (3) 呼吸或哭泣？ 提出一項新建議，對於出生時不需要復甦的足月出生 和早產兒，延遲臍帶夾閉 30 秒以上應是適當的做法。 但目前的證據不足以針對出生時需要接受復甦的新生兒， 提出臍帶夾閉的相關建議。 應記錄體溫做為結果的預測因子和品質指標。 初生時未窒息的新生兒，自出生後至住院期間，體溫應 穩定維持於 36.5 °C 至 37.5 °C 之間。 應避免體溫過高 ( 體溫超過38 °C)，因為可能引起潛 在相關風險。 37
- 38. 新生兒復甦 如果嬰兒出生時經過胎便污 染的羊水，並且出現肌肉張 力不良和不當用力呼吸的情 況，應該在輻射加溫器下方 進行復甦的起始步驟。 完成起始步驟後，如果嬰兒 沒有呼吸或心率低於 100 次 / 分鐘，應開始進行 PPV。 不建議在此種情況下例行插 管進行氣管抽吸 38
- 39. Thanks for your attention! Questions? Comments? 39
Editor's Notes
- 依損傷嚴重程度評分，每個解剖區域只挑選最嚴重的創傷分數(AIS 分數最高者)，再選取最高分的三個區域來計算，只能選三個。 ISS = 三個最高 AIS 分數（最嚴重創傷）平方的總合 舉例：頭頸 2 分，顏面 1 分，胸部 4 分，腹部 3 分，肢體 2 分，外觀軟組織 2 分， ISS = 42＋3 2＋3 2 = 16＋9＋4 = 29 分。 ISS 分數最低 0 分，最高 75 分。75 分有三種可能： 1. 有３或３個以上區域之 AIS 分數為 5 分，5 2＋5 2＋5 2 = 75。 2. 只要有一個區域 AIS 分數為 6 分，ISS 一律為 75 分。 3. 到院前死亡，ISS 一律為 75 分。 ISS < 9 分為輕度外傷，ISS 9-15 分為中度外傷，ISS > 16 分為嚴重外傷（可申請重大傷病卡）。外傷死亡率與 ISS 分數及傷患年齡成正相關。ISS 分數愈高或年齡愈大，死亡率愈高。 Bull(1975 年)發現 ISS 分數、死亡率與年齡之相關性，以下約有 50% 死亡率： 15-44 歲，ISS=40 45-64 歲，ISS=29 >65 歲，ISS=20 PCPC 1 Normal 2 Mild cerebral disability 3 Moderate cerebral disability 4 Severe cerebral disability 5 Coma or vegetative state 6 Brain death
- Welcome to an introduction of the 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Advancements in medical science are continuously evolving and improving survival outcomes. 2010 marks the 50th anniversary of the first medical publication to document cardiac arrest patient survival following closed chest compression. The American Heart Association is more dedicated than ever before to reducing death and disability from cardiovascular diseases and stroke. The 2010 Guidelines are based on an international evidence evaluation process: hundreds of resuscitation scientists and experts evaluated, discussed, and debated thousands of peer-reviewed publications to identify the most current evidence-based information. By implementing the recommendations in the new guidelines, you will be up-to-date with the latest scientific studies and current best practices in resuscitation science. Bystanders, first responders, and healthcare providers all play crucial roles in the Chain of Survival. Together, we continue to improve survival for victims of cardiac arrest by emphasizing high-quality chest compressions, increasing frequency of bystander CPR, and providing excellent post-cardiac arrest care.
- To deliver acute and critical care to the youngest of patients, you must be up-to-date with the latest science and treatment recommendations for pediatric advanced life support (PALS). In the 2010 AHA Guidelines for CPR and ECC, you will find evidence-based best-practices about pediatric resuscitation and training. This introductory course will familiarize you with important changes affecting PALS and the scientific rationale behind the new recommendations.
- By completing this course, you will be able to describe relevant science updates to Pediatric Basic Life Support, Pediatric Advanced Life Support, and Neonatal Resuscitation. You will gain new information about best practices related to team approaches and systems of care. And you will be able to find in-depth information about the Guidelines from AHA's Highlights and Circulation publications. You also will be prepared to take next steps in your education, certification, and implementation of the AHA recommendations.
- This new section of the 2010 AHA Guidelines for CPR and ECC has been added to address the growing body of evidence guiding best practices for teaching and learning resuscitation skills. Recommendations here are meant to improve implementation of the Chain of Survival and best practices related to teams and systems of care. This section of the course highlights the recommendations specific to advanced life saving courses.
- Many key issues in pediatric basic life support are the same as those in adult basic life support: emphasizing high-quality chest compressions of adequate rate and depth, allowing chest recoil after each compression, minimizing interruptions in chest compressions, and avoiding excessive ventilation. For basic life support in children, there are new recommendations on compression depth and the use of AED for infants, and a de-emphasis of the pulse check for healthcare providers.
- As for adults, initiate CPR for infants and children with chest compressions rather than rescue breaths. The pediatric BLS sequence is now C-A-B. For a single rescuer, begin CPR with 30 compressions. For resuscitation of infants and children by two or more rescuers, begin with 15 compressions. This major change in CPR sequencing to compressions before ventilations (C-A-B) led to vigorous debate among experts in pediatric resuscitation. Because most pediatric cardiac arrests are due to progressive respiratory failure or shock, rather than sudden primary cardiac arrest, both intuition and clinical data support the need for ventilations and compressions for pediatric CPR. For resuscitation of the newly born, see the Neonatal Resuscitation section of this course.
- Evidence from radiologic studies of the chest in children suggests that compression to one-half the anterior-posterior diameter may not be achievable. However, effective chest compressions require pushing hard. The new data suggests an achievable depth of about 1½ inches (4 cm) for most infants and about 2 inches (5 cm) for most children.
- To achieve effective chest compressions, rescuers should compress at least one-third the anterior-posterior dimension of the chest. This corresponds to approximately 1½ inches (about 4 cm) in most infants and about 2 inches (5 cm) in most children. 原因： 一項成人研究指出，胸部按壓深度超過 2.4 英吋(6 cm) 可能造成傷害。
- 2015 ( 更新)： 在小兒證據不足的情況下，為了盡量簡化 CPR 訓練，在嬰兒和兒童採用成人的建議胸部按壓速率 (100 至 120 次/ 分鐘)，是適當的做法。 2010 ( 舊版)：「 快速按壓」：胸部按壓速率每分鐘至少100 次。 原因： 一項成人記錄研究證實，非常快速的按壓速率可能造成胸部按壓深度不足。
- 2015 ( 更新)： 應為心臟停止的嬰兒和兒童，進行傳統CPR ( 急救人工呼吸和胸部按壓)。小兒心臟停止的病例大部分為窒息性，有效 CPR 仍必須包含通氣。不過由於單純按壓 CPR 可有效救治原發性心臟停止病患，若施救者不願意或無法進行人工呼吸，建議可為心臟停止的嬰兒和兒童進行單純按壓 CPR。 2010 ( 舊版)： 理想的嬰兒和兒童 CPR 應包含胸部按壓和通氣，不過單純按壓比完全不施予 CPR 好。 原因： 大量記錄研究證實，認定窒息性小兒心臟停止包含絕大部分到院前小兒心臟停止) 的病例，接受單純按壓 CPR 的預後較差。
- The review of the pediatric advanced life support literature resulted primarily in the refinement of existing recommendations, rather than the creation of new recommendations. New sections have been added on resuscitation of infants and children with congenital heart disease, including those with single ventricle, those with single ventricle after palliative procedures, and those with pulmonary hypertension. Also, several recommendations for medications have been revised.
- The recommendation regarding calcium administration is stronger than in past AHA Guidelines: routine calcium administration is not recommended for pediatric cardiopulmonary arrest in the absence of documented hypocalcemia, calcium channel blocker overdose, hypermagnesemia, or hyperkalemia. Routine calcium administration in cardiac arrest provides no benefit and may be harmful. Etomidate has been shown to facilitate endotracheal intubation in infants and children with minimal hemodynamic effect. Etomidate is not routinely recommended if evidence of septic shock.
- 如果有適當的流程、專業知識技術和設 備，對於患有心臟疾病且發生 IHCA 的兒童，可考慮使用 ECPR。
- While there have been no published results of prospective randomized pediatric trials of therapeutic hypothermia, based on adult evidence, therapeutic hypothermia (to 32oC – 34oC) may be beneficial for adolescents who remain comatose following resuscitation from sudden witnessed out-of-hospital VF cardiac arrest. Therapeutic hypothermia (to 32°C to 34°C) may also be considered for infants and children who remain comatose following resuscitation from cardiac arrest.
- 一項大型的 IHCA 和 OHCA 小兒觀察研究發現， 相對於高氧血症 (Pao2 超過 300 mm Hg)，血氧正常 ( 定 義為 PaO2 介於 60 到 300 mm Hg 之間) 可提高存活至離 開小兒加護病房的比率。成人及動物研究顯示，死亡率增 加與高氧血症有關。同樣，ROSC 後的成人研究也證實， 低血碳酸會使病患預後較差。
- 原因： 審議證據顯示，不論羊水是否受到胎便污染，新 生兒復甦術應遵守相同原則；也就是說，如果出現肌肉張 力不良且不當用力呼吸時，應在床上加溫器下方完成復 甦的起始步驟 ( 保溫和維持體溫、擺放嬰兒的姿位、視情 況清除呼吸道分泌物、擦乾和刺激嬰兒)。完成起始步驟 後，如果嬰兒沒有呼吸或心率低於 100 次/ 分鐘，應開 始進行 PPV。專家較重視避免傷害 ( 亦即延遲提供袋瓣罩 通氣、程序可能造成的傷害)，勝於例行氣管插管和抽吸 介入的未知效益。應依據個別嬰兒的狀況，進行適當介入 以支持通氣並開始氧合作用，包括插管和抽吸 ( 如果呼吸 道阻塞)。