NRP PALS Update 2017 2017-10-24 Publishable Copy€¦ · criAcally ill newborns (NRP) and children...
Transcript of NRP PALS Update 2017 2017-10-24 Publishable Copy€¦ · criAcally ill newborns (NRP) and children...
2017-10-24
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NRP/PALSUpdate:SavingTinyLivesin2017
AndreJakubow,MD,CCFP(FPA)November2017
TheBeautyofNRP&PALS• Awell-runcodeisaworkofart.
• SimpleintervenAonssavelives.KidsrespondgraAfyinglyfasttotherightintervenAons(e.g.effecAvePPVinNRP).
• Andyet… skillsdecayfastandImeisoftheessence:manytasks,allatonce…– SystemaIcApproachhelps– TeamDynamics/HumanFactors/CRMhelp
ObjecIves:
1. Refresh&rehearsestepstotakewhenresuscitaAngcriAcallyillnewborns(NRP)andchildren(PALS)
2. DescribethemainchangestoNRPandPALSguidelinesin2015updatesandmorerecentfindings
3. StrengthengoodpracAcesinteamdynamics&“crewresourcemanagement”toopImizeoutcomes
4. ReviewfrequenterrorsNRPersandPALSiesmakeDoesNOTreplaceanofficialcourse;opinionsmyown;evidencemostlylow-quality,butwillbemenAoned
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Method:ResuscitaIonGame
• We’regoingtoplayagame.• Step-by-step“walkthrough”,imaginary‘codes’:1NRP,1PALS
• Ateachstep:“OneCueèXResponses”• Giveyourbestguess,shortanswer(afewwords)• ONEanswerperperson.Allowedto“pass”• Quickanswersplease!KeepItMoving!Mistakesareexpected–&partofthefun.
IntroducAons
• CCFP(McGill),FP-Anesthesia(U.ofT.)• PALSInstructor(HSFC)• NRPInstructor(CPS)• ProfessionalInterests:familymedicine;medicaleducaAon;anesthesia;simulaAon;crisisresourcemgmt
• ConflictsofInterest:none
Warm-upRound:“ACodeBlue/Pink/Trauma/OutdoorEmergencyisunfolding.Whatareyourbasicstepstoprepare?”(3
keyresponses)
1. SceneSafety:Fire/wire/gas/glass/guns/thugs/drugs2. TeamBriefing:TakeLead!AssignRoles!GetHelp!
“I’lltaketheLeadrole.“Jeff-canyoubetheAirwayperson,startcheckingpulse&breathing;”“Sandra-canyouputontheMonitorsnow;”“Laura-pleasestartanIVandgetMedsready…”
3. AssignEquipmentCheck:e.g.STATICS-MIMM
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SCENARIO1:NRP
Cue1:YouArrive@Delivery.“BabyComingSoon,YouReady?”(4keyresponses)
1. (SceneSafety)2. TeamBriefing:– TakeLeadRole!Assign
TeamRoles!3. EquipmentCheck:
“STATICS-MIMM+4”
4. AskFOURpre-birthquesIons:– MulA-baby?– GestaAonalAge?– RiskFactors?– Meconium?
Cue2:Birth(!)(3keyresponses)
• Ask3post-birthquesAons:– “Term?”(i.e.“isGAapprox.correct?”)– “Tone?”– “BreathingorCrying?”
• IFall“YES”es:– …relax…rouAnecare
• IFany“NO”s:– BRINGTOWARMERand…
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Cue3:BabyHitsWarmer(4)• PosiAonforopenA/W≈
Sniffing(≈“shldrroll”)• “ClearAirwayIfNeeded”• “Dry-SAmulate-Remove
WetTowels”
(Hiddenstep:)u AskMonitorspersonto
assessHR&BS(A/WpersonmaybebusysucAoning)
AWordOnMeconium
• FORMERLY,NRPadvisedthatALL“non-vigorous”babieswithmeconiumbeintubatedandsucAonedthroughtheETTpriortogivingPPV.
• 7thediAonNRPrecommendsnotrouInelyintubaAngandsucAoningsuchbabies
• BUTit’ssAllanopAon• SHOULDbeconsidered(attheSofMRSOPA)iftroublevenAlaAng
Cue4:“HR<100”{OR}respsineffecIve(1keyresponse+3secondary)
• STARTPPVwithroomair(21-30%if<35wkGA)
• WheneverPPVisstarted:– think“Maskonface?Satprobe
onRthand;{ANDECGleadsonchestagoodideatoo}”
Hiddenstephere:• ImmediatelyAskMonitorsPerson
toauscultatetoconfirmwhetherPPVisworking:
• *HRrisesufficienttoprovisionallyprovegoodPPV;
• otherreassuringsignsshouldbesought,e.g.audibleBS,visiblechestrise,(ETCO2)
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Cue5:PPVstarted,butHRnotrising<15sec.Whattodo?(1)
• Theproblemisalways*lackofvenAlaAon.
• SoassumeyourvenIlaIonisfaultyfirst.OnlybreakthatassumpAonw/greatcauAon,andif:– definiteCHESTRISE– definiteBREATHSOUNDSbilat– definite+ETCO2(rare
excepAons)*
DON’TBLAMEBABY.
BlameYOURfaultyPPV.
DOMRSOPA.
*ExcepAonsSOrarethatyouDONOTworryaboutthemforthefirst15secondsofPPV.DoMRSOPA!
ComputerHelpDeskTechnicians
List“MRSOPA”steps.(6)
• MaskSeal• ReposiIon(…theairway…≈shoulderroll)
• SucIon• OpentheMouth
• Pressureincrease(to30cmH2O,cauAouslyto≤40)• Alternateairway(ETTrecommended,orLMA)
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MRSOPA:“AlternaIveAirway”
…@“A”ofMRSOPA,youdecidetointubate…
Cue5B:“MRSOPA”complete,butnoHRrise<15sec.Whattodo?
GloocimpersonaIonKovacsetal.,CanJAnesth(2017)64:320
• R/OesophagealintubaAon(sustained+ETCO2bestr/o;alsochestrise,brsnds,mist)
• R/OendobronchialintubaAon(tubeslippedintoofar?)–checkETTdepth
• ConsiderLMA• Asalways:first&only&
constantly-to-be-repeatedquesAonisareyouSUREyou’revenAlaAngthelungs:ETCO2?Chestrise?Breathsounds?
Cue5B:“MRSOPA”complete,butnoHRrise<15sec.Whattodo?
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Cue6:definitely-goodPPVx30s,butHRstays<60(1response,+5linkedacIons)
• STARTChestCompressn’s
• WheneverCC’sstarted:“Thumbsonthechest=>
1. (TUBEintheTRACHEA,)2. 100%O2onBLENDER,3. ECGleadsonCHEST…AndprobablyagoodAmeto
4. Get‘M/M’starIngaUVC5. CallforMOREHELP/
NEONATOLOGY*CRMpoint:Tigercountryahead;anAcipaAng;gevngslowtasksstartedearly,offloadingfuture
Cue7:DefinitelygoodPPV&CCs.WhentorecheckHR?SIll<60…whattodo?(3)
Epinephrine;recallthisisonlyindicatedifHRremains<60arer:• Atleast30secEFFECTIVEPPV
(w/chestmvt,±ETCO2)• FOLLOWEDBY
addnl60secofCC’sw/100%O2Dose:0.1ml/kgof0.1mg/mlepinephrine(≈usualdoseis≈0.3ml),viaUVC/IV/IOInthesesituaAons,• Considerhypovolemia• ConsiderPTX
• Re-evalwhetherETTreallywell-placed/ETCO2…
Cue8:Baby’sHRimproves,theystarttocry.Yousavedthem,congrats…anyfinalacIons?(2)
Postresusc.CareTeamdebriefingTalkwithparentsGiveselfhigh-five
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NRP:Summary/7thedΔs• SceneSafety• TakeLeadRole!AssignTeamRoles!(=TeamBriefing)• EquipmentCheck(Isuggest“STATICS-MIMM+4”)• 4pre-birthQ’s• 3post-birthQ’s• IniAalSteps(posiAon,clearairwayPRN,dry,sAmulate);assessHR/BS;
meconiumsucAonnotrouAne,butOKPRN.IfHR<100orapnea/gasping:• PPV:21%O2,~30%for<35wGA
Maskonfaceèsatprobehand&ECG.Immed.ChestRise/HR/BScheck.• MRSOPAimmediately(<15sec)ifPPVineffecAve• ChestCompressions(if30seceffecAvePPV&sAll<60):thumbsonchest
èO2to100%-Tubeintrachea– ECGonchest– GetaUVCrolling(IOifunable)– Callformore/neonatologyhelp
• Epinephrine;crystalloid,blood;explicitlyconsiderPTX/hypovol.
Barriers&SoluAons
• Barriers:Cost(ECGmonitors,O2blenders),ChallengingSkills,InfrequentExposure
• SoluIons:Budget,regularsimulaAon(esp.UVC,ETT/LMA);supportforrecurrenttraining;collegialneighbourhoodanestheAstsinterprofessional/regional/prov/natsupport
MOVINGONFROMBABIESTOKIDS…
Imagecredit:h~ps://www.highlights.com/parents/arAcles/helping-babies-deal-transiAons
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ALovelyStrollThroughtheMall
(InterruptedbyacommoAon)
• Asmallcrowdmillingaround…
Cue1:CommoIon,?UnconsciousChild(3Responses)
• SceneSafety!• TeamBriefing:Take
Charge!AssignTeamRoles!(?Parents?)
• (EquipmentCheck!)=gettheequipmentmovingtowardyou
• CheckforResponsiveness
• SimultaneousPulse&BreathingCheck
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Cue2A:Unresponsive,NOBrthg,NOPulse(2)• Call9-1-1,SendforAED• StartCPRasC-A-B:Compressions,thenVenAlaAons;“IrememberBLS!”
• RaIo: “30:2foreveryone,except…” two-rescuerchild&infant,inwh.case15:2
• LEAVEtoPhonefirst?orCPR-2-mins-Then-Leave-and-Phone?
– “LEAVEtofindphonefirstforeveryone,except…”One-Rescuer,Child&Infant,Unwitnessed:DO2cycles’CPRbeforeleavingtophone.KidsburnO2fast;UNWITNESSEDimpliespossibleprolongedhypoxia.
• Depth: 1/3chestwalldiameter(“4cminfants,5cmchild, 5-6cmadults”seemssillytome)
• Rate: 100~120/min• Other: MinimizeInterrupAons;FullChestRecoil
– Newin2016:“considerafeedbackdevice”
Cue2B:Unresponsive,breathingNO,pulseYES(afreebie)
• RescueBreathing– (1breathq3~5sec)=12~20/min
Cue2C:Responsive,butpoorlyso,andobviouslyhe’sbreathingandhasapulsegiventhatanyresponsivenesswouldbe
impossiblewithoutthese(1response)
• PALSPrimary(1°)Survey– A– B– C– D– E
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HowTo:Evaluate-IdenAfy-Intervene
• ConAnuouscycle• DoingPrimarySurvey+/-SecondarySurv.+/-Dxtests=“Evaluate”
PALS1°Survey“A”(4responses)
• Look:chest/abdomenmovement
• Listen:Stridor,Gurgling• Feel:ifnecessary• Fixissuesfound– a/wpatencywillbemaintainableSpontaneouslyorw/Simple(jawthrust,sucAon,Heimlich,OPA/NPA),orw/Advanced(BMV,CPAP,ETT/LMA/cricothyrotomy)
PALS1°Survey“B”(5responses)
• Rate/Pazern• Volume:chestexpansion
• Effort(WorkOfBreathing):retracAons,etc.
• BreathSounds(byauscultaAon)
• O2Sat
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PALS1°Survey“C”(5responses)
• HeartRate&Rhythm• BP
• CapRefill• SkinTemperature• PeriphPulses
PALS1°Survey“D”(3responses)
• AVPUorGCS• Pupils• Glucose
PALS1°Survey“E”(2responses)
• Expose/Examine/ExtremiIes:– Rash-purpura/Trauma/Bruising
• CoreTemperature
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Yourfindingsinthiskid:
• PALS1°Survey,“Evaluate”:– A:stridor/snoring,AWneedingjawthrusttomaintain;?puffyface
– B:RR35,shallowVt,diffusewheezing,O2satunk.– C:sweatyextremiAes,shock,caprefill4sec;PPweak– D:anxious,responsivetoPain,pupilsOK,Gluc.unk– E:urAcarialrash,tempunknown
• Whatcanyou“IdenAfy”theproblemas?
?
Imageavailableat:h~p://www.bbc.com/news/health-25950422
Cue3:1°SurveyDone,NowWhat?
• ConsiderInterven-ing
• OrfurtherEvaluat-ion,ifsAlluncertain
• Eitherway,a“SUMMARIZING”statementishelpfulatthisjuncture(CRM!)
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Evaluate-IdenAfy-Intervene• StateType&Severity• Type:
– “Respiratory”/“Circulatory”/“Both”• UpperAW• LowerAW• LungTissue• DisorderedControl
– Shock:Cardiogen./Hypovol./ObstrucAve/DistribuAve
• Severity:– Resp.Distressvs.Resp.Failure– Shock:Compensatedvs.Hypotensive
CRMpoint:SUMMARIZING:“OKfolks,thislookslikesomekindofshocktome,becauseofhis{slowcaprefillandcoldextremiAesw/normalBP},andwhat‘Type’ofshock,I’mnotsureofyet…”
EffecAveTeamDynamics/CRM
• SummarizingStatements(SHAREyourmentalmodel!)
• ClearRoles&ResponsibiliAes• ClearMessages• Closed-LoopCommunicaAon• MutualRespect• ConstrucAveIntervenAon• KnowingOne’sLimitaAons
h~p://www.royalcollege.ca/rcsite/ppi/educaAonal-resources-e
Cue3:What’sPALS2°Survey? (2)
• SAMPLEHistory,plus• Head-to-toeExam
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ListSAMPLEhx?(6)
• Signs&Symptoms• Allergies• Meds• PastMedHistory• LastMeal(“Mostrecentmeal”)• Events
• Thendo“Head-to-toeexam”tofinish2°srvy
Intervene:Epinephrine,10mcg/kg,IM
Cue4:2°SurveyFinished…(1response)
• ConsiderDiagnosIcTests
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Cue5:DiagnosIcTestsOrdered…(1response)
• Re-“Evaluate”ABCDE• Summarize
• Post-Resusc.Care• Consultcolleagues• DiscusswithpaAent/parents
• TeamDebriefing…
TheKidSurvives!…Congrats
PALS:OverallAlgorithm• IniIalImpression/Pulse&Brthgsimultaneously;if+:• 1°Survey:– A:look/listen/feel/fix– B:rate/volume/effort/auscultate/O2sat– C:HR/BP/CapRefill/SkinTemp/PeriphPulses– D:Pupils,GCS/AVPU,Glucose– E:Expose/Examine/ExtremiAes
• 2°Survey:– SAMPLEhistory– Head-to-toeexam
• DiagnosIcTests
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Misc.Changes:2015PALS• AtropinepremedicaIon:notrecommendedforemergency
intubaAon(conflicAngevid)–sIllhaveitreadyjustincase
• FluidresuscitaIoninsepIcshock:DOuseiniAal20ml/kgcrystalloidforkidswithshock,butnotfor‘severefebrileillnesswithoutshock’.Low-resourcesevngs(i.e.non-ICUsevngs)shouldprobablyavoidexcessivefluids–basedonAfricanstudy-kidswithdengue/malaria
• TargetedTemperatureManagement:pedsout-of-hospitalcardiacarrestwhoareunresponsivea�erROSC,either32-34or36-37.5CelsiusareopAons;probablymostimportant(&low-effort)toavoidhypERthermia(THAPCA-in/out-of-hospitaltrials)
QuesAons?
• ?
Recap• PrinciplesofNRP&PALSsimilar:– Arrestscausedbyresporshock>>cardiovascularcauses– Pre-Arrest(compensated/‘distress’stage)>>arrest(hypotensive/decompensated/organ-‘failure’stage)
– IdenAfy&Fix“rapidly-fatal”threatsfirst– VenIlaIon/OxygenaIonprovide+++benefit;circulatorysupport(fluids/inotropes)in2ndplace
– Capnography(ETCO2)o�enagoodidea– BLS/QualityofCPR/EarlyDefibmoreimportantthanmeds(e.g.epi);find&treatcausewithspecificRx’s• E.g.Hypovolemia?Fluids.Anaphylaxis?Epinephrine.Sepsis?AnIbioIcs&sourcecontrol…
• SystemaIcAprch,OrganizedTeamDynamics/CRM
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ThankYou
• ThankyouforyourcommitmenttoexcellentcareofcriAcallyillnewbornsandchildren
• THEEND…nowsomefuntopicsforfurtherdiscussion…
OurKidsDependOnYourSkills
CommonMistakesPALS/NRPersMake1. TheBradycardiaBlunder2. SystemaIcAssessmentSlipups3. RealLifeHesitaIon4. EsophagealIntubaIonsUnrecognized5. AlgorithmConfusion6. EquipmentCheckFoibles7. CommunicaIonBreakdowns
CommonMistake1:BradycardiaBlunder
• “HR<60withpoorperfusion.ThatmeansIneedtostartCC’sSTAT!”Right?
• FALSE.
• EffecPvePPV/O2/CO2mustbeestablished‘x30sec’beforeCCsbecomeanopAon.*commonthread(NRP&PALS)!
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PALS2015BradycardiaAlgorithm
CommonMistake2:SystemaAcAssessmentSlipups
• “not-so-systemaAc”/“JumpingtoCnclsns”• FixaPonerrors:“Thismustbesepsis!”
• Remedy:Askyourself,“Whatelsecouldthisbe?”• UsewriYenguide/checklisttohelpyounotskipsteps
CommonMistake3:RealLifeHesitaAon
• “Idon’twanttoputa*tube*inthisbaby!”• “Anumbilicalveincatheter?ThatseemsdrasPc…”• Unexpectedevents,‘formerly’-healthybabies
• Remedy:ExpectsomeAmestohavetoprovideinvasivetherapiestobabiesyoudidn’tthinkweresick,ifnowtheyaresick
• IfETT/LMAindicated,be~ertouseitthannot• UVC(placedcorrectly)isafew-cm-lengthcatheterinaneasilyaccessiblevein,reliable,relaAvelysafe,o�enfasterthanperiphIVandsaferthanIO
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CommonMistake4:EsophagealIntubaAonsUnrecognized
• EvenexperiencedMDsputETTsdowntheesophagus• That’sforgivable• What’snotforgivableisnotrecognizingitimmediately• EvenlessforgivableisconAnuingtheresuscwith‘falsesenseof
security’that“thekid’sbeenintubated,soA/BareOK”whenthey’renot
• Remedy:UseALLyourclues(especially+ETCO2);ConsidertheETTanuntrustworthy,slipperycreaturethatsomeAmesisin,someAmesslipsout,doesn’tstaywhereit’sput;ANYproblemsrechecktheETT,ETCO2,chestrise
• BreathSounds&“ChestRise”aresubjecAve&canbemisperceived;“wishfulthinking”
CommonMistake5:AlgorithmConfusionAges&Breakpoints
BIRTH
~1MO
1yr-10kg
8YRS
Puberty
Algorithm NRP
PALS
ACLS
PreferredAEDType
ê
AEDw/PedsDoseA~en’r
AdultAED
ManualDefib
BabyPaddlesunAl1yr/10kg
ChildPaddles/Pads
AdultPads/Paddles
AlgorithmConfusion:Compression/VenAlaAonRaAos
• 30:2foreverybody!• Except2-RESCUERCHILD&INFANT,inwhichcaseit’s15:2.
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AlgorithmConfusion:“ShouldIStay,OrShouldIGo?”
• IfALONEwithNOPHONE• “LEAVEallvicAmstorun,callEMS&comeback!”• exceptUNWITNESSEDCHILD&INFANT,• inwhichcaseyoudo2’(5cycles)CPRfirst,THENrun&callEMS&comeback.– (Wedothese“kickstarter”compressionswithoutdelaybecauseitwasUNWITNESSED,sotheymayhavebeenhypoxicforalongAme,andthey’reCHILD/INFANT,thereforetheyburnO2rapidly.)
6:EquipmentFoibles:SuggestedChecklist:“STATICS-MIMM”
• S–“Scopes”• T–“Tubes”• A–“Airways”• T–“Tape”• I– “Introducer”(Stylet)• C–“Circuit”=srcofPPV(±O2)– Blender@21%,21-30%blo35wGA
• S–“SucAon”– Bulb,Flex,MecAsp
• M–“Monitors”– SaO2,ECG,ETCO2;(BP,temp,artline…)
• I–“IV”/UVC• M–“Meds”• M–“Mask”/LMA
PLUS(NRP):• Warmer• BabyBaggie<32wks• NGtubes• Blankets
CommonMistake7:CommunicaAonBreakdowns
• Can“somebody”getthemonitorson?• “Let’s”getoxygenonthispaAent?• Does“anyone”havethechart?• Canwegive“some”epinephrine?
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CommunicaAon:AdapAngAirTrafficLingotoNRP
Yamada&Halamek(JPeds2015)
Otherresuscstudiessince2015• “Balancedfluids”CritCareMed.2017Apr21.doi:10.1097/CCM.0000000000002365.[Epubahead
ofprint]ResuscitaAonWithBalancedFluidsIsAssociatedWithImprovedSurvivalinPediatricSevereSepsis.Comparedto“unbalancedfluids”(NS),“balancedfluids”hadbeYermortality(12.5%vs16%),AKIprevalence(16vs19%)and3.0vs3.3daysonpressors
• Two-thumb“moreuseful”thantwo-finger(JMaternFetalNeonatalMed.2017Mar5:1-12)• CurrOpinCritCare.2016Dec;22(6):527-532.FluidresuscitaIonforacutekidneyinjury:anempty
promise.–ratherthanEGDT,anewconceptualmodelisproposed:“Rescue–OpPmizaPon–StabilizaPon– DeescalaPon”.
• TimePercepIonduringNeonatalResuscitaIon.JPediatr.2016Oct;177:103-7.WeunderesPmatePmeelapsed– whetherwereportfeelingstressedorpreparedornot.
• ResuscitaAon.2016Oct;107:25-30.doi:10.1016/j.resuscitaAon.2016.07.231.Epub2016Aug2.VenIlaIonfracIonduringthefirst30sofneonatalresuscitaIon.– NorwegianstudyshowingthatPmespentnotvenPlaPngisabout40%infirst30s
• JPaediatrChildHealth.2016Feb;52(2):141-6.doi:10.1111/jpc.13085.FluidresuscitaIontherapyforpaediatricsepsis.:balancedsoluPonspreferred;colloids=>renaldysfuncPon,shouldbeavoidedforsepsis
• Targetedtemperaturemanagement:-?Avoidhyperthermia,butin-hospitalcardiacarreststudycalledTHAPCA-IHcompared33vs36.8degC,in-hospitalarrests:disconAnuedearlyforlackofdifferencebeingfound
• DebriefingFramework:“REFLECT”:Reviewtheevent,EncourageteamparAcipaAon,Focusedfeedback,Listentoeachother,Emphasizekeypoints,Communicateclearly,andTransformthefuture(PediatrEmergCare.2017Apr18)
PICUPearls1. Ifeverunsureasubtlesignindicatessevereillness,JUST
ASKapediatrician/PICU.Happytochat.2. Mostcommonsubtlesignsof“sick”kid:
1. Tachycardia2. Silenttachypnea(asignofacidosis)3. SubtlechangesinmentaAon
3. KidsDECOMPENSATEquickly:“terrifying”4. HypotensionLATE,VERYOMINOUS,don’tdoubtit;ACT
STAT.5. Eventeens,whensepAc,o�en+myocardialdysfunxn,
notvasoplegia:needinotropy,notpurepressor6. MyocardiAscanpresentlikesepsis
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ThankYou
Availableuponrequest