Advanced Paediatric Life Support sixth edition This new edition is also Preface to the first edition Advanced Paediatric Life Support: The Practical 5th–95th centile BP Systolic Boys Girls 5th centile 50th centile 95th. Advanced Paediatric Life Support: The Practical Approach, 5th Edition. Show all authors. Martin Samuels. Martin Samuels. John Wiley & Sons Ltd. Chichester. Advanced Paediatric Life Support, a training course The 5th Edition of the APLS course is therefore now obsolete. ALSG has released How to access the PDF chapters of the Course Manual, linked to each VLE module.
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Part I: Introduction; Part II: Life Support; Part III: The Seriously Ill Advanced Paediatric Life Support: The Practical Approach, Fifth Edition. APLS 5th Edition. Australia & New Zealand Version Life-threatening asthma – emergency treatment. • High-flow IV aminophylline. • Respiratory support. Advanced Paediatric Life Support: A Practical Approach to Emergencies, 6th Edition - This Wiley - Blackwell app-book is developed by.
Therefore, an observational pain scale appears to be more appropriate in this setting. Pain management Environment The emergency department and the treatment room of the paediatric ward can be frightening places for children. Visibility Others can see my Clipboard. By the time that cardiac arrest occurs, there has already been substantial damage to various organs. Emergencies in children generate a great deal of anxiety — in the child, the parents and in the medical and nursing staff who deal with them.
Tse Paediatric Nephrology, Newcastle C. Vallis Paediatric Anaesthesia, Newcastle A. Walker Paediatric Anaesthesia, Glasgow L. White Toxinologist, Adelaide S. Wood Paediatric Surgery, Liverpool J.
Wyllie Neonatology, Middlesbrough A. Preface to the first edition Advanced Paediatric Life Support: The Practical Approach was written to improve the emergency care of children, and has been developed by a number of paediatricians, paediatric surgeons, emergency physicians and anaesthetists from several UK centres.
It is the core text for the APLS UK course, and will also be of value to medical and allied personnel unable to attend the course. It is designed to include all the common emergencies, and also covers a number of less common diagnoses that are amenable to good initial treatment. The remit is the first hour of care, because it is during this time that the subsequent course of the child is set.
The book is divided into six parts.
Part I introduces the subject by discussing the causes of childhood emergencies, the reasons why children need to be treated differently and the ways in which a seriously ill child can be recognised quickly. Part II deals with the techniques of life support. Both basic and advanced techniques are covered, and there is a separate section on resuscitation of the newborn. Part III deals with children who present with serious illness.
Shock is dealt with in detail, because recognition and treatment can be particularly difficult. Cardiac and respiratory emergencies, and coma and convulsions, are also discussed.
Part IV concentrates on the child who has been seriously injured. Part V gives practical guidance on performing the procedures mentioned elsewhere in the text. Finally, Part VI the appendices deals with other areas of importance. Emergencies in children generate a great deal of anxiety — in the child, the parents and in the medical and nursing staff who deal with them. We hope that this book will shed some light on the subject of paediatric emergency care, and that it will raise the standard of paediatric life support.
An understanding of the contents will allow doctors, nurses and paramedics dealing with seriously ill and injured children to approach their care with confidence. Preface to the sixth edition The AdvancedPaediatricLifeSupport APLS concept and courses have aimed from inception 23 years ago to bring a structured approach and simple guidelines to the emergency management of seriously ill and injured children. The manual was and continues to be an important part of the course, but it has also come to be used as a handbook in clinical practice.
This has been a real tribute to the contributors of this text, both current and past editions. The course has changed since the last edition to reflect the changes in health service provision, as well as the increasing evidence base of medical knowledge.
This has been accompanied by the need to develop increasingly expert teams to provide health care. Trauma care has undergone the greatest revision and the importance of team working, utilising the skills of many different disciplines and knowing when and how to seek additional help are hopefully clearly reflected within the provider course. The sixth edition of the manual reflects the pace of change of medical science and practice, the international nature of APLS and the increasing recognition of the importance of human factors in providing the best emergency care.
Whilst the sixth edition is current, we hope that APLS providers will see the introduction of an app, paperless courses and an enhanced electronic learning resource with chronic and specialist conditions. Contributions and ideas are always welcome. To ensure this, ALSG has had to be responsive to the different styles, languages, cultures and clinical facilities found in many different countries.
It is with the help of so many enthusiastic and dedicated local health professionals that APLS has flourished. We hope that new as well as current providers of emergency paediatric practice appreciate the changes. The material found in these sources, as well as in this manual, is all brought together by the increasing numbers of experts that have contributed to this update. We thank them and all our instructors, who have provided helpful feedback.
We ask that this process does not stop, so that we can begin the process that will support the development of the next edition. Martin Samuels Sue Wieteska Manchester Acknowledgements A great many people have put a lot of hard work into the production of this book, and the accompanying advanced life support course. The editors would like to thank all the contributors for their efforts and all the APLS instructors who took the time to send us their comments on the earlier editions.
ALSG wish to thank the following: Association of Paediatric Anaesthetists Dr A. Doherty, Paediatrics, Dorchester; Dr H. Gandhi, Paediatric Cardiology, Birmingham We are also grateful to the following groups who have advised on the clinical content of chapters relevant to their specialism: European Resuscitation Council: European Trauma Course Mr K. Walmsley, Anaesthetics, Eastbourne; Dr A.
Zibners, Paediatric Emergency Medicine, London Finally, we would like to thank, in advance, those of you who will attend the Advanced Paediatric Life Support course and other courses using this text; no doubt, you will have much constructive criticism to offer. However, practice may change in the interim period. We will post any changes on the ALSG website, so we advise that you visit the website regularly to check for updates www.
The website will provide you with a new page to download. This information is then used whenever the course is updated to ensure that the course provides optimum training to its participants. Powered by VitalSource version — a digital, interactive version of this textbook which you own as soon as you download it. Colour code, highlight and make digital notes right in the text so you can find them quickly and easily Organize: Keep books, notes and class materials organized in folders inside the application Share: Exchange notes and highlights with others Upgrade: Visit www.
Visit http: Visit the app store to download the VitalSource Bookshelf: Advanced Paediatric Life Support: Edited by Martin Samuels and Sue Wieteska. Published by John Wiley Sons, Ltd. This has been related to improvements in many areas such as maternal education, access to clean water, access to food, immunisation against an increasing number of infectious conditions, and improved access to healthcare services.
This approach is potentially applicable in many different settings across the world. Among the most important differences are the substantially lower physiological reserves in children, particularly young children. A consequence of this is that in the face of injury or severe illness their condition may deteriorate more rapidly than would be expected for adult patients.
Thus particular attention has to be paid to timeliness and effective support of the respiratory and cardiovascular systems. Learning outcomes After reading this chapter, you will be able to: By the time that cardiac arrest occurs, there has already been substantial damage to various organs.
This is in contrast to situations more common in adults where the cardiac arrest was the consequence of cardiac arrhythmia — with preceding normal perfusion and oxygenation. Standardised structure for assessment and stabilisation The use of a standardised structure for resuscitation provides benefits in many areas.
Firstly it provides a structured approach to a critically ill child who may have multiple problems. The standardised approach enables the provision of a standard working environment, ensuring that all the necessary equipment is available as required. The use of the standardised structure enables the entire team to know what is likely to be expected of them and in what sequence. There may well be discussion around the optimum sequence of resuscitation, but in this course a particular approach has been accepted as being reasonable, and most in keeping with the available research information.
It is likely that aspects of this approach will change over time, and in fact it may be appropriate to modify the approach in particular working environments and contexts. Once basic stabilisation has been achieved, it is then appropriate to investigate the underlying diagnoses and proceed to definitive therapy.
Occasionally, definitive therapy such as surgical intervention may be a component of the resuscitation. Thus part of traininginpaediatriclifesupportmustfocusonunderstandinghowthehumanresourcesavailableforaparticularresuscitation episode can be utilised most effectively.
Ongoing care until admission to appropriate care In most parts of the world it is impossible to transfer critically ill children into intensive care units or other specialised units within a short time of their arrival in the emergency area. Thus it is important to provide training in the ongoing therapy that is required for a range of relatively common conditions once initial stabilisation has been completed.
At birth a child is, on average, a 3. They are capable of limited movement, have immature emotional responses though still perceive pain and are dependent upon adults for all their needs. Competent management of a seriously ill or injured child who may fall anywhere between these two extremes requires a knowledge of these anatomical, physiological and emotional differences and a strategy of how to deal with them.
Weight The most rapid changes in weight occur during the first year of life. An average birth weight of 3. After that time weight increases more slowly until the pubertal growth spurt. Clearly the most accurate method for achieving this is to weigh the child on scales; however, in an emergency Figure 1. If this is not possible, various formulae or measuring tapes are available.
The Broselow or Sandell tapes use the height or length of the child to estimate weight. The tape is laid alongside the child and the estimated weight read from the calibrations on the tape.
This is a quick, easy and relatively accurate method. Various formulae may also be used although they should be validated to the population in which they are being used. Whatever the method, it is essential that the carer is sufficiently familiar with it to be able to use it quickly and accurately under pressure.
When the child arrives, you should quickly review their size to check if it is much larger or smaller than predicted. If you have a child that looks particularly large or small for their age, you can go up or down one age group. Particular anatomical changes are relevant to emergency care. Airway The airway is influenced by anatomical changes in the tissues of the mouth and neck. In a young child the occiput is relatively large and the neck short, potentially resulting in neck flexion and airway narrowing when the child is laid flat in the supine position.
The face and mandible are small, and teeth or orthodontic appliances may be loose. The tongue is relatively large and not only tends to obstruct the airway in an unconscious child, but may also impede the view at laryngoscopy. Finally, the floor of the mouth is easily compressible, requiring care in the positioning of fingers when holding the jaw for airway positioning.
Table 1. Infants less than 6 months old are primarily nasal breathers. As the narrow nasal passages are easily obstructed by mucous secretions, and as upper respiratory tract infections are common in this age group, these children are at particular risk of airway compromise. Adenotonsillar hypertrophy may be a problem at all ages, but is more usually found between 3 and 8 years. This not only tends to cause obstruction, but also may cause difficulty when the nasal route is used to pass pharyngeal, gastric or tracheal tubes.
The cricoid ring is oval in shape, and thus passage of a round endotracheal tube will almost always result in a leak around the tube.
Although uncuffed endotracheal tubes have been used preferentially in children, there is increasing evidence that cuffed endotracheal tubes may be advantageous in many settings. However, the use of a cuffed tube requires meticulous attention to size, to cuff pressure and to exact placement of the endotracheal tube in the correct position.
The trachea is short and soft. Overextension of the neck as well as flexion may therefore cause tracheal compression. Breathing The lungs are relatively immature at birth. Both the upper and lower airways are relatively small, and are consequently more easily obstructed. This may partially explain why so much respiratory disease in children is characterised by airway obstruction.
Infants rely mainly on diaphragmatic breathing. These children are consequently more prone to respiratory failure. The ribs lie more horizontally in infants, and therefore contribute less to chest expansion. In the injured child, the compliant chest wall may allow serious parenchymal injuries to occur without necessarily incurring rib fractures. For multiple rib fractures to occur the force must be very large; the parenchymal injury that results is consequently very severe and flail chest is tolerated badly.
Circulation At birth the two cardiac ventricles are of similar weight; by 2 months of age the RV: LV weight ratio is 0.
During the first months of life the right ventricle RV dominance is apparent, but by 4—6 months of age the left ventricle LV is dominant. Narrow nostrils Large tongue Loose teeth Horseshoe-shaped epiglottis High anterior larynx Compressible floor of mouth Figure 1. This means that in infants and small children, relatively small absolute amounts of blood loss can be critically important. Small children, with a high ratio, lose heat more rapidly and consequently are relatively more prone to hypothermia.
Physiological Respiratory The infant has a relatively greater metabolic rate and oxygen consumption. This is one reason for an increased respiratory rate. In the adult, the lung and chest wall contribute equally to the total compliance.
In the newborn, most of the impedance to expansion is due to the lung, and is critically dependent on the presence of surfactant. The lung compliance increases over the first week of life as fluid is removed from the lung.
Figure 1. This is an important consideration during procedures such as endotracheal intubation. The immature infant lung is also more vulnerable to insult. Cardiovascular The infant has a relatively small stroke volume 1. At the same time the stroke volume increases, as the heart gets bigger and muscle mass relative to connective tissue increases.
As the stroke volume is small and relatively fixed in infants, cardiac output is principally related to heart rate. The practical importance of this is that the response to volume therapy is blunted when normovolaemic because stroke volume cannot increase greatly to improve cardiac output.
By the age of 2 years, myocardial function and response to fluid are similar to those of an adult. Systemic vascular resistance rises after birth and continues to do so until adulthood is reached. Immune function At birth the immune system is immature and, consequently, babies are more susceptible than older children to many infections such as bronchiolitis, septicaemia, meningitis and urinary tract infections.
Maternal antibodies acquired across the placenta provide some early protection but these progressively decline during the first 6 months. Infants may be particularly susceptible to infectious diseases in the period between waning of maternal antibodies and development of their own antibodies sometimes in response to immunisation.
Breastfeeding provides increased protection against respiratory and gastrointestinal infections. Psychological Children vary enormously in their intellectual ability and their emotional response.
Particular challenges exist in communicating with children and as far as possible easing their fear of the circumstances they find themselves in. Communication Infants and young children either have no language ability or are still developing their speech.
This causes difficulty when symptoms such as pain need to be described. Even children who are usually fluent may remain silent. This causes additional distress to the child and adds to parental anxiety. Physiological parameters, such as pulse rate and respiratory rate, are often raised because of it, and this in turn makes clinical assessment of pathological processes such as shock more difficult.
This means that the child may think that the problem has been caused by some bad wish or thought that he or she has had. Knowledge allays fear and it is therefore important to explain things as clearly as possible to the child. Explanations must be phrased in a way that the child can understand. Play can be used to do this e.
But importantly, parents too must be supported and fully informed at all times. You should also be aware that there are some important differences in children: The infrequent and, the often unforeseen, nature of the events adds to the anxiety for all. The structured approach will enable a clinician to manage emergencies in a logical and effective fashion and assist in ensuring that vital steps are not forgotten.
The structured approach focuses initially on identifying and treating any immediate threats to life: Clinical interventions to reverse these immediate threats comprise resuscitation. After resuscitation is commenced the next step is to identify the key features that in any serious illness or injury give the clinician a signpost to the likeliest working diagnosis. From this, the best emergency treatment can be initiated.
The final phase of the structured approach is to stabilise the child, focusing on achieving homeostasis and system control and leading on to transfer to a definitive care environment, which will often be the paediatric intensive care unit. Throughout this book the same structure will be used so that the clinician will become familiar with the approach and be able to apply it to any clinical emergency situation.
Success depends on each team member carrying out his or her own tasks and being aware of the tasks and the skills of other team members. The whole team must be under the direction of a team leader.
Communication is no less important with clinical colleagues. When things have gone wrong, a fault in communication has often been involved. It is an essential clinical risk management step, and also a tool for optimisation of resource allocation in any emergency. While the names of the triage categories and the target times assigned to each name vary from country to country, the underlying concept does not.
We use triage to identify children who require urgent intervention. The priorities of triage may alter for instance in an epidemic it may be as important to get potentially uninfected children away from possible infection as soon as possible.
Remember also that being triaged green does not mean that a child does not have a serious problem that requires specialist attention. It simply means that it can wait a little while. It is important to make sure that the family understand the nature of the triage process and why they are apparently being ignored while another child receives treatment.
Triage decision making There are many models of decision making, each requiring three basic steps. These are: This method uses the following five steps: This phase is always necessary whatever the method used. Gather and analyse information related to the solution Once the presentation has been identified, discriminators can be sought at each level. Discriminators, as their name implies, are factors that discriminate between patients such that they allow them to be allocated to one of the five clinical priorities.
They can be general or specific. The former apply to all patients irrespective of their presentation, whilst the latter tend to relate to key features of particular conditions. Thus severe pain is a general discriminator, but cardiac pain and pleuritic pain are specific discriminators. General discriminators would include life threat, pain, haemorrhage, conscious level and temperature.
Any cessation or threat to the vital ABC functions means that the patient is in the immediate group. Thus the presence of an insecure airway, inspiratory or expiratory stridor, absent or inadequate breathing, or shock are all significant. Painassessmentandmanagement is dealt with later in this chapter.
Children with severe pain should be allocated to the very urgent category, while those with moderate pain should be allocated to the urgent category. Any child with any lesser degree of pain should be allocated to the standard category.
If haemorrhage is catastrophic, death will ensue rapidly unless bleeding is stopped. These children must be treated immediately. A haemorrhage that is not rapidly controlled by the application of sustained direct pressure, and that continues to bleed heavily or soak through large dressings quickly, should be treated very urgently.
Children with a history of unconsciousness should be allocated to the urgent category. A hot child over Evaluate all alternatives and select one for implementation Clinicians collect a huge amount of information about the children they deal with.
The data are compared to internal frameworks that act as guides for assessment. The presentational flow diagrams developed by the Manchester Triage Group provide the organisational framework to order the thought process during triage. Once the priority is allocated, the appropriate pathway of care begins. Monitor the implementation and evaluate outcomes Triage categories may change as the child deteriorates or gets better. It is important, therefore, that the process of triage clinical prioritisation is dynamic rather than static.
To achieve this end all clinicians involved in the pathway of care should rapidly assess priority whenever they encounter the child. Furthermore, any changes in priority must be noted and the appropriate actions taken. Insuchcircumstancesthenecessaryassessmentsshouldstillbecarriedout,butassecondary proceduresbyareceivingnurse. Attention to control of pain is not only more humane but it enhances care, as inadequate analgesia can be detrimental to the critically ill child.
Bronchoconstriction and increases in pulmonary vascular resistance caused by pain can lead to hypoxia, whereas good pain control facilitates the assessment of the severity of illness.
Recognition and assessment of pain There are three main ways in which we recognise that a child is in pain: Firstly, listening to the child for statements that they are in pain. Thirdly, anticipating pain because of the event the child has experienced, such as fracture, burn or other significant trauma. The purpose of pain assessment is to establish, as far as possible, the degree of pain experienced by the child so as to select the right level of pain relief.
Additionally, reassessment using the same pain tool will indicate whether the pain management has been successful or whether further analgesia is required — the assess, treat and reassess cycle.
The use of pain tools and protocols in the emergency setting has been shown to shorten the time to delivery of analgesia. Pain assessment at triage in the emergency situation is unique and therefore a pain assessment tool, specifically designed for this situation, is desirable. Therefore, an observational pain scale appears to be more appropriate in this setting.
This is clearly not the case in the emergency department. The tools can then be used again to assess the efficacy of the intervention and to guide further analgesia. Pain management Environment The emergency department and the treatment room of the paediatric ward can be frightening places for children.
Negative aspects of the environment should be removed or minimised. An attractive, decorated environment with toys, mobiles and pictures should be substituted. If time permits, they should contribute to the pain management plan by relating previous pain experiences and successful relief measures.
If a play therapist is available they may be able to assist with the preparation and the procedure. Physical treatments: Parents need some guidance on how to help their child during the procedure beyond just being present.
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