Understanding that resuscitation tools are available is an essential component of PALS. These adjuncts are broken down into two subcategories: medical devices and pharmacological tools. A medical device is an instrument used to diagnose, treat, or facilitate care. Pharmacological tools are the medications used to treat the common challenges experienced during a pediatric emergency. It is important that thorough understanding is achieved to optimally care for a child or an infant that needs assistance.
The relative softness of bones in young children makes intraosseous access a quick, useful means to administer fluids and medications in emergency situations when intravenous access cannot be performed quickly or efficiently. Fortunately, any medication that can be given through a vein can be administered into the bone marrow without dose adjustment. Contraindications include bone fracture, history of bony malformation, and insertion site infection.
Figure 8
Bag-Mask Ventilation
When performed appropriately, bag-mask ventilation is an important intervention in PALS. Proper use requires proper fit: the child or the infant’s mouth and nose should be covered tightly, but not the eyes. When possible, use a clear mask since it will allow you to see the color of their lips and the presence of condensation in the mask indicating exhalation.
The two most common types of bag-masks are self-inflating and flow-inflating. While a self-inflating bag-mask should be the first choice in resuscitations, it should not be used in children or infants who are breathing spontaneously. Flow-inflating bag-masks, on the other hand, require more training and experience to operate properly as the provider must simultaneously manage gas flow, suitable mask seal, individual’s neck position, and proper tidal volume. The minimum size bag should be 450 mL for infants and young and/or small children. Older children may require a 1000 mL volume bag. Proper ventilation is of utmost importance as insufficient ventilation leads to respiratory acidosis.
Figure 9
Endotracheal Intubation
Endotracheal (ET) intubation is used when the airway cannot be maintained, when bag-mask ventilation is inadequate or ineffective, or when a definitive airway is necessary. ET intubation requires specialized training and a complete description is beyond the scope of this handbook.
Basic Airway Adjuncts
Oropharyngeal Airway
The oropharyngeal airway (OPA) is a J-shaped device that fits over the tongue to hold the soft hypopharyngeal structures and the tongue away from the posterior wall of the pharynx. OPA is used in persons who are at risk for developing airway obstruction from the tongue or from relaxed upper airway muscle. If efforts to open the airway fail to provide and maintain a clear, unobstructed airway, then use the OPA in unconscious persons. An OPA should not be used in a conscious or semiconscious person because it can stimulate gagging and vomiting. The key assessment is to check whether the person has an intact cough and gag reflex. If so, do not use an OPA.
Nasopharyngeal Airway
The nasopharyngeal airway (NPA) is a soft rubber or plastic un-cuffed tube that provides a conduit for airflow between the nares and the pharynx. It is used as an alternative to an OPA in persons who need a basic airway management adjunct. Unlike the oral airway, NPAs may be used in conscious or semiconscious persons (persons with intact cough and gag reflex). The NPA is indicated when insertion of an OPA is technically difficult or dangerous. Use caution or avoid placing NPAs in a person with obvious facial fractures.
Suctioning
Suctioning is an essential component of maintaining a patent airway. Providers should suction the airway immediately if there are copious secretions, blood, or vomit. Attempts at suctioning should not exceed 10 seconds. To avoid hypoxemia, follow suctioning attempts with a short period of 100% oxygen administration. Monitor the person’s heart rate, pulse oxygen saturation, and clinical appearance during suctioning. If a change in monitoring parameters is seen, interrupt suctioning and administer oxygen until the heart rate returns to normal and until clinical condition improves. Assist ventilation as warranted.
- Only use an OPA in unresponsive persons with no cough or gag reflex. Otherwise, OPA can stimulate vomiting, aspiration, and laryngeal spasm.
- An NPA can be used in conscious persons with intact cough and gag reflex. However, use carefully in persons with facial trauma because of risk of displacement.
- Keep in mind that the person is not receiving 100% oxygen while suctioning. Interrupt suctioning and administer oxygen if any change in monitoring parameters is observed during suctioning.
Basic Airway Technique
Inserting an OPA
STEP 1: Clear the mouth of blood and secretions with suction if possible.
STEP 2: Select an airway device that is the correct size for the person.
- Too large of an airway device can damage the throat.
- Too small of an airway device can press the tongue into the airway.
STEP 3: Place the device at the side of the person’s face. Choose the device that extends from the corner of the mouth to the earlobe.
STEP 4: Insert the device into the mouth so the point is toward the roof of the mouth or parallel to the teeth. • Do not press the tongue back into the throat.
STEP 5: Once the device is almost fully inserted, turn it until the tongue is cupped by the interior curve of the device.
Inserting an NPA
STEP 1: Select an airway device that is the correct size for the person.
STEP 2: Place the device at the side of the person’s face. Choose the device that extends from the tip of the nose to the earlobe. Use the largest diameter device that will fit.
STEP 3: Lubricate the airway with a water-soluble lubricant or anesthetic jelly.
STEP 4: Insert the device slowly, moving straight into the face (not toward the brain).
STEP 5: It should feel snug; do not force the device into the nostril. If it feels stuck, remove it and try the other nostril.
Tips on Suctioning
- When suctioning the oropharynx, do not insert the catheter too deeply. Extend the catheter to the maximum safe depth and suction as you withdraw.
- When suctioning an ET tube, remember the tube is within the trachea and you may be suctioning near the bronchi/lung. Therefore, sterile technique should be used.
- Each suction attempt should be for no longer than 10 seconds. Remember the person will not get oxygen during suctioning.
- Monitor vital signs during suctioning and stop suctioning immediately if the person experiences hypoxemia (oxygen sats less than 94%), has a new arrhythmia or becomes cyanotic.
- OPAs too large or too small may obstruct the airway.
- NPAs sized incorrectly may enter the esophagus.
- Always check for spontaneous respirations after insertion of either device.
AED Infants & Children
If you look around the public places you visit, you are likely to find an Automated External Defibrillator (AED). An AED is both sophisticated and easy to use, providing life-saving power in a user-friendly device. This makes the device useful for people who have no experience operating an AED and allows successful use in stressful scenarios. However, proper use of an AED is very important. The purpose of defibrillation is to reset the electrical systems of the heart, allowing a normal rhythm a chance to return.
- Criteria for AED Use:
- No response after shaking and shouting.
- Not breathing or ineffective breathing.
- No carotid artery pulse detected.
AED STEPS FOR CHILDREN AND INFANTS
- Retrieve the AED (Figure 10a).
- Open the case.
- Turn on the AED.
- Expose the infant or the child’s chest (Figure 10b).
- If wet, dry chest.
- Remove medication patches.
- Open the pediatric AED pads (Figure 10c). If pediatric pads are not available, use adult pads. Ensure that the pads do not touch.
- Peel off backing.
- Check for pacemaker or defibrillator; if present, do not apply patches over the device.
Figure 10
- Apply the pads (Figure 10d).
- Upper right chest above the breast.
- Lower left chest below the armpit.
- If pads will touch on the chest of an infant, apply one pad on the anterior chest and another pad on the posterior of the infant instead.
Do not use AED in water.
Figure 10
AED STEPS FOR CHILDREN AND INFANTS CONTINUED
- Ensure wires are attached to AED box (Figure 10e).
- Move away from the person (Figure 10f).
- Stop CPR.
- Instruct others not to touch the person.
- AED analyzes the rhythm.
- If message reads “Check Electrodes,” then:
- Ensure electrodes make good contact.
- If message reads “Shock,” then shock.
- Resume CPR for two minutes (Figure 10g).
- Repeat cycle.