approach to PALS

1. By
DR.NIHAL ABDEEN
PEIDATRIC REISDENT

3. Apply team dynamic
Clear roles and responsibilities -Team leader: Clear define all tem -members roles in clinical setting
.
-Team Members: seek out and perform clearly defined tasks
appropriate to the level of competence
Know your limitation -call for assistance early rather than waiting until patient
deteriorate to the point that help is critical.
-seek advice from more experienced personnel when the patient
condition worsen despite primary treatment.
Construction intervention -team leader: ask that a different intervention be started if has a
higher priority .
Team member: suggest alternative drug or dose in a confident
manner.
-question a colleague who is about to make a mistake .
Knowledge sharing Team leader: Encourage sharing information and ask for suggestions
.
Team member: share information with other team members.
Summarizing and reevaluating Team leader :the patient statue, intervention that have been
performed ,assessment finding .
-Team member: clearly draw attention to significant changes in the
patient condition .

4. Positions of 6 person high
performance teams
Team leader
Airway
monitory
Medication
Compressor
Timer recorder

5. Evaluate :
-primary assessment
-secondary assessment
-Diagnostic assessment
Intervene
Identify

6. Identify
type Severity
Respiratory :
-upper airway obstruction
-lower airway obstruction
-lunge tissue diseases
Disordered control of breathing
-Respiratory distress
Respiratory failure
Circulatory :
-hypovolemic shock
-distributive shock
-Cardiogenic shock
-Obstructive shock
-Compensated shock
-Hypotensive shock
Type and severity of potential problems

7. Intervene
May include:
-position the child to maintain airway
-activating the emergency response
-Start CPR
-placing the child on a cardiac monitor and pulse oximeter
-Administering O2
-Supportive ventilation
-starting medications and fluids (eg.nebulizers treatment
,IV/IO fluids bolus)

8. Evaluate
-After each intervention
-When the child condition
changes or deteriorates

9. Initial impression-pediatric assessment triage
(your initial observation)
• Consciousness
• Abnormal Tone
• Abnormal speech cry
Appearance
• abnormal sounds ,abnormal
position ,increase work of
breathing ,decrease respiratory
effort, retraction ,flaring, apnea
or gasping) .
Work of breathing
• cyanosis
• pallor
• Dusky
• mottling)
Color of the skin

10. Clinical assessment tools
Clinical assessment Brief description
Primary assessment ABCDE
Secondary assessment A focused history and a focused examination
Diagnostic assessment -labs
-Radiographs
-Or any advanced tests that help to identify
the child physiologic condition and diagnosis

11. Primary assessment
Assessment:
• respiratory rate
• Chest rise
• Noisy breathing (grunting
,stridor or wheezing )
• Effort and using of accessory
muscle (nasal flaring ,head
bobbing, retraction, apnea )
• pulse oximetry.
Intervention:
-provide high flow oxygen
-Bag mask ventilation
-Advanced airway
-avoid excessive ventilation
Air way
• if the air way is patent?
• Is the air way clear ?
• If no ,intervene :
-Maintain air way patency by
position
-Suction as indicated
-Advanced airway
(e,supraglottic airway or
endotracheal tube).
-
Breathing
Assessment
• Hear rate .
• Peripheral pulses + central
• Blood pressure
• Capillary refill
• Skin color and temp
Interventions:
-obtain IV/IO access
Consider fluids resuscitation
Circulation

12. Assessment :
-quickly assess for responsiveness ,level of
consciousness pupillary response to light .
-AVPU pediatric response scale: Alert, Voice,
Pain, Unresponsive.
-Presence of hypoglycemia (rapid bedside
glucose )
-Glasgow Coma Scale: Eye Opening, Verbal
Response, Motor Response .
Interventions:
-spinal motion restrictions
Correct hypoglycemia
Consider naloxone for acute opioid toxicity.
Disability Exposure
Assessment :
-remove clothing to perform physical
examination (anterior and posterior )
-looking for any signs of trauma ,bleeding
,burns, rashes ,unusual markings, medical
alert bracelets .
-Temperature .
Interventions:
-ensure normothermia
-control bleeding
Decontamination

13. Secondary assessment
●This portion of the evaluation includes a thorough head to toe physical examination, as well as a
focused medical history that consists of the "SAMPLE" history:
•S: Signs and symptoms
•A: Allergies (medication ,foods ,latex, etc )
•M: Medications (over the counter ,vitamins ,inhalers, herbal supplements ,medication that can
be found in the child environment )
•P: -health history (premature birth ,previous illnesses ,hospitalization )
-significant underlying medical problems (asthma ,COPD ,cong.heart diseases ,aarythmia
,congenital airway abnormality, seizures ,head injury ,brain
tumores,diabetes,hydrocephalus,neuromuscular diseases) .
-past surgeries
-immunization status

14. •L: Last meal (time and nature of last intake of liquid or food (including breast feeding or bottle
feeding in infant )
time between the last meal and presentation of current illness can affect treatment and
management of the condition eg.possible anesthesia ,possible intubation .
•E: -Events leading to current illness or injury (eg. onset sudden or gradual ,type of injury )
-treatment during interval from onset of disease or injury until evaluation .

15. Focused physical
examination
Head to toe examination
Illness Areas to evaluate
Respiratory distress -Nose /mouth (signs of obstruction,
nasal congestion ,stridor ,mucosal
edema )
-Chest/lung
-Heart (tachycardia ,gallop ,or murmur)
-level of alertness (eg. anxiety secondary
to hypoxia )
Suspected heart failure and /or
arrhythmias
-Heart (gallop or murmur )
-Lungs (crackles ,SOB ,intolerance of
supine position )
-Abdomen( hepatomegaly (RHF)
-Extremities (peripheral edema )
Trauma -Abdomen
-Chest
Some examples of areas to assess during physical examination for certain illnesses
and injuries

16. Diagnostic assessment
-ABG
-VBG
-CBG
-FBC
-central venous O2 saturation
-central venous pressure monitoring
-invasive arterial pressure monitoring
-CXR
-ECG
-ECHO
-PEFR

20. References