Pediatric Advanced Life Support - Essay Example

Pediatric Advanced Life Support Pediatric Assessment (level of consciousness, breathing, color) Precise assessment of a child with an acute illness or suffering from an injury requires certain crucial knowledge and skills. Most of the children presenting the ER often have a mild, moderate illness and injury and stay alert. In the assessment of these patients’ illnesses and injuries, several methodologies and severity scales can be incorporated for assessing the levels of consciousness. However, these methodologies often lack accuracy, especially when it comes to infants and toddlers (Donnelly, 2009). This implies that although the methods will help in classifying the moderate to critically ill or injured child, it will however not help in the recognition of crucial signs that help in noting the early symptoms of system strain in the sick or wounded child who is still operating well or looks well. 2. Evaluation-primary assessment, secondary assessment, diagnostic tests Diagnostic tests refer to any test that is used to determine the existence of an illness or disease. For example, there are cases where the test is carried out in order to fully diagnose someone or to affirm that a patient is free of any disease. Diagnostic tests include CT scans, bronchoscopy, x-rays, oesophageal ultrasound and angiography. The main aim of carrying out primary assessment is to immediately identify life threatening problems. The primary assessment mainly aims at stabilizing the patient, identify life-threatening conditions in the patient in order of risk and initiate for treatment immediately. Secondary assessment will come after the primary assessment has been fully carried out and the patient’s vital signs have all been assessed. It comprises of checking the patient history and physical examination of the patient. 3. Respiratory Assessment, Circulatory Assessment Respiratory assessment consists of four main components, which include inspection, palpation, percussion and auscultation. Inspection involves the medical practitioner using their eyes and ears to assess a varying number of things about their patients. Some of the main things the medical practitioner can observe include pursed lip breathing, noisy breathing, skin color, coughing, respiratory rate, patterns, and chest wall abnormalities. In the palpation phase, the medical practitioner uses their fingers and hands during the physical examination. They will touch and feel the patient’s body in order to determine the consistency, size, texture, tenderness and location of a body organ or body part. Percussion on the other hand involves the technique of tapping body hands by using the fingers and certain instruments during the physical examination. It is often used to determine the presence or absence of fluids in certain body organs and the borders, size and consistency of body organs (Baren, 2008). Percussion of a body organ normally produces a certain sound that will in turn indicate the presence of a certain tissue within that particular body part or organ. Lastly, there is auscultation. During auscultation, the patient is supposed to sit upright while taking in deep breaths through the mouth. Any outside noise should be eliminated if possible. The medical practitioner will then listen to the sounds arising within the body organs. While assessing circulation, the medical practitioner should determine whether the child has a pulse or is in shock. One should keep in mind that children and infants are only capable of tolerating only small amounts of blood loss before they suffer circulatory compromise. It is important to assess and control any bleeding early in the circulatory assessment. Circulatory assessment should not only focus on the circulatory status but also try to correct any inadequate circulation to other body organs of the infant or child. The main measures of circulatory assessment are heart rate and blood pressure. However, changes in the skin percussion can be used as indicators of compensated shock. 4. Types of shock: (Hypovolemic, distributive, cardiogenic, obstructive) a. Cardiogenic Shock In cardiogenic shock, the forward flow of blood is often inadequate due to a defect in the cardiac function. It normally happens when the heart cannot properly pump blood through the body system. This could be due to impairment caused to the heart from myocardial infarction (commonly known as heart attack) that results in enough damage to the heart to impair its proper functioning. Furthermore, a disease or virus could also be a cause of cardiogenic shock. b. Hypovolemic Shock Hypo simply means lack of, while volemic refers to fluid volume. In an instance when a patient is injured and profusely bleeding, the volume of blood that the body is able to deliver reduces substantially resulting to the patient experiencing hypovolemic shock. This kind of shock is quite common in patients who have suffered from trauma and have external bleeding. However, a patient can equally suffer from internal bleeding from an illness or injury, which can quickly result in the patient falling into a hypovolemic shock state. c. Distributive Shock Distributive shock occurs when the intravascular volume is markedly abnormal due to a decrease in vascular resistance, such as it happens to occur in fainting where blood pools in the venous instead of the arterial portion of the blood flow. Cardiac output may be augmented, normal or small in patients who experience distributive shock. Several causes may cause distributive shock such as septic shock, neurogenic shock, anaphylactic shock and acute adrenal insufficiency. However, there are drugs that result in vasodilation thus resulting in the patient experiencing distributive shock (Baren, 2008). d. Obstructive Shock The main characteristic of obstructive shock is the impedance of sufficient cardiac filling of the ventricles leading to a significant decrease in the cardiac output. As the distribution of blood decreases, the patients’ tissues may begin to die because of lack of oxygen and necessary nutrients. There are certain patients who have a high risk of suffering from obstructive shock such as those on bed rest and those who have mobility issues and do not move around so much. Furthermore, patients with chest injuries have a higher risk of suffering from obstructive shock. 5. Diagnostic tests: Arterial blood gas Arterial blood gas is the measurement of the oxygen level in the blood flowing through the arteries. The process normally involves puncturing an artery with a thin needle and drawing a small amount blood from the artery. The most commonly chosen puncture for this process is the radial artery. The main reason for carrying out this test is on order to determine the blood pH level, the part pressure of carbon dioxide and oxygen and the level of bicarbonate in the blood. In addition, there are instances where the test determines the lactate level. However, the required sample to carry out the arterial blood gas test may be difficult to acquire because of the diminished pulses in some patients and constant patient movement (King, 2008). Diminished pulses may be a reflection of low blood pressure or poor peripheral circulation in the patient as a result of the illness. The constant movement is due to the pain that comes as a result of the arterial puncture. In an infant who weighs less than 30 pounds, arterial blood can be obtained from the capillary stick instead, and in the case of a newborn, it is obtained from the umbilical catheter. Although arterial puncture is a skill that can easily be learned, there may be instances where certain complications may come about as a result. Such complications include trauma and occlusion, infection, vessel spasm and embolization. However, in a case where a skilled practitioner performs arterial puncture, it offers safe and reliable information, which is useful in patient management. 6. Venous Blood Gas Venous blood gas (VBG) is a substitute method used in the measurement or estimation of carbon dioxide and pH in the blood that does not require arterial puncture. VBG is most preferred as compared to ABG, particularly for patients in the intensive care unit given that they already have a central venous catheter from which the venous blood can easily be obtained. The VBG test is useful in assessing oxygen and carbon dioxide gas exchange, respiratory functions such as hypoxia and acid/base balance in the patients. Furthermore, it can also incorporated in the evaluation of asthma, chronic obstructive pulmonary disease and various types of lung disease such as coronary artery disease. Abnormal results of the VBG tests may be due to metabolic, lung and kidney diseases. However, patients who may have a history of head or neck injuries will also likely have abnormal VBG results (Donnelly, 2009) 7. Hemoglobin and Hematocrit Both the hemoglobin and the hematocrit refer to specific characteristics of the red blood cells, but they however measure different things. The hemoglobin is compound in the red blood cells that transports oxygen to other cells in the body. The hemoglobin tests measures how much hemoglobin is present in the blood. The test is often carried out when doctors want to determine the patient’s general health and patients’ blood chemistry. The hematocrit test on the other hand is carried out to determine the total percentage of the volume of the blood that contains the red blood cells. The measurement will be dependent on the number of the red blood cells and the size of the red blood cells. 8. Central venous pressure monitoring The central venous pressure (CVP) is the direct measurement of blood pressure in the central veins adjacent to the heart. It shows the average right atrial pressure and are most of the times used to estimate the right ventricular preload. Although the CVP does not measure the blood volume directly, it may however be used from time to time. In CVP monitoring, a catheter in inserted through a vein and advanced until the tip lies in or on the right atrium. Given the fact that there are no valves present between the junction of the vena cava and the right atrium, the pressure reading at the end of the diastole directly transfers to the catheter. CVP monitoring is important because it gives the necessary information pertaining to the body’s blood volume or fluid status and the right ventricular function. CVP can be monitored intermittently or continuously. There are three main approaches used in the measuring of the pressure in the right atrium. One would be using a water manometer attached to the attached to the CV catheter. Second would be using a line placed directly into the right atrium which is then attached to the transducer system. Lastly, would be using a proximal lumen of a pulmonary artery catheter. The normal CVP ranges from 5 to 10 cm H2O. A number underlying conditions that may alter venous return, flowing blood volume or cardiac activity may in turn impact on the CVP. For instance, if the circulating blood was to increase due to increase in venous return to the heart, the CVP is most likely to rise. On the other hand, if the flowing volume decreases, the CVP will drop. Overdistention or underfilling of the venous collecting system can easily be identified by monitoring the CVP before the clinical symptoms become apparent. The CVP can be measures in instances where the patients with hypertension are not responding to the basic clinical management implemented, or in patients requiring infusions or inotropes, or in patients who seem to be experiencing continuing hypervolemia secondary to major fluid loss or shifts (Parthasarathy, 2013). 9. Invasive Arterial pressure monitoring Invasive blood pressure (IBP) monitoring is a commonly employed method in the Intensive Care Unit (ICU) and in the operating room. It entails the insertion of a catheter into a suitable artery and displaying the recorded pressure wave on the monitor. Patients who are undergoing invasive blood pressure monitoring should be under close supervision constantly given that they may likely suffer blood loss in any case the line comes off. The method is often reserved for critically ill patients who are likely to experience rapid changes in their blood pressure. Normal or acceptable blood pressure varies from one patient to another depending on the patient’s age, health status and clinical information. At birth, the expected blood pressure is normally 80 mmHg. This number rises steadily through childhood, such that in a young adult the expected blood pressure is 100/80 mmHg. In order to determine whether the recorded reading is normal for that particular patient, it shall be compared to the “normal” for that patient. In the incorporation of this technique in blood measurement, the cannula is place into an artery (normally radial, dorsalis pedis or brachial). The cannula will then be connected to a sterile system filled with fluid which is then connected to an electronic patient monitor. The main benefit of this method is that the pressure is measures beat-by-beat and the waveform easily readable and displayed for monitoring. 10. Chest x-ray, echocardiogram, peak expiratory flow rate Peak flow rate is a simple, quantitative, reproducible measurement of the existence and severity of air flow obstruction. It is an important tool often used in the monitoring, exacerbations and daily long term monitoring. Peak expiratory flow (PEF) can be measured by the use of Mini Wright peak flow meters which are inexpensive and affordable to many. PEF is a quick and easy way for health care practitioners to measure and record predicted normal PEF values, while taking into consideration the height and age of the child as a point of reference. However, the value which is considered “normal” is of a rather wide range and hence the test is dependent on the effort of the pediatrician. Health care practitioners can easily teach their patients to carry the PEF test on their own given the easy nature of the method. 11. Respiratory distress and failure Respiratory distress is a state of increased work of breathing, while respiratory failure is a state inadequate oxygenation or ventilation. Respiratory failure may or may not be preceded by respiratory failure. Assessment of an infant’s respiratory status often begins with the Pediatric Assessment Triangle. Infants and children often have unique clinical condition that may result in respiratory problems. Respiratory distress is a form of respiratory failure that comes about as a result of varying disorders that may cause fluid to accumulate in the lungs and low oxygen levels in the blood. According to research, quick identification of respiratory distress in in the pediatric patient is crucial before it escalates into respiratory failure. The main symptoms of respiratory failure often manifest themselves in the patient 24 to 48 hours after injury, but may take up to 5 days to be notable in the patient. The patient is likely to have shortness of breath, and usually shallow and rapid breathing. Crackling or wheezing sounds can be heard when the pediatrician auscultates the lungs. The small oxygen availability in the blood will also cause the child’s skin to be cyanotic. Conversely, respiratory failure is a situation in which one or all the gas exchange functions fails i.e. oxygenation and carbon dioxide elimination. The situation can either be acute or chronic. It is safe to construe that this condition will likely occur in a patient whose respiratory distress was not handled properly. The main difference between respiratory distress and respiratory failure is that in respiratory distress the patent is still breathing, while in respiratory failure the patient stops breathing completely (Taussig, 2008). Respiratory failure normally occurs when the patients lungs are incapable of properly removing carbon dioxide from the infants blood. This will in turn result in too much accumulation of carbon dioxide in the system which will harm the patient’s body organs. There are certain illnesses that that affect infants breathing that will result in respiratory failure such as chronic obstructive pulmonary disease (prevents air from properly flowing in and out of the system) and spinal cord injuries (may damage nerves that control breathing). 12. Management of upper respiratory airway obstruction The most shared cause of upper respiratory obstruction is the tongue. The management of a patient with upper respiratory obstruction will vary depending on the cause of the obstruction, the level of skill and competence of the rescuer, and the availability of aids to perform the necessary airway techniques. Obstruction of the upper airway is a life threatening condition that if not properly managed may possibly result in the patient’s death. The main aim is to secure the patient from getting a heart attack or possibly suffering irreversible brain damage that can take place within minutes of the airway obstruction.. 13. Management of Lower respiratory Airway obstruction. Lower respiratory airway obstruction normally results from the infection or irritation from certain particular particles or substances. It normally occurs between the larynx and the narrow passages of the lungs. The main symptoms include air trapping, an increased AP diameter and barrel chest. The common simple ways of helping a patient with lower airway obstruction include chin life, jaw thrust and performing adjuncts. 14. Intraosseous access. In a critical resuscitation circumstance, after the airway has been secured and adequate breathing and gas exchange fully established back to normal, the next priority should be to obtain vascular access. Most of the times, this is difficult to attain especially in children and infants. The physiologic progressions of shock and hypothermia with subsequent vascular tightening which are normally notable in the resuscitative state may later on complicate the matter and make it worse. In addition, the expertise of most medical practitioners when it comes to attending to children widely varies. Instraosseous access has been used for years and is considered safe, reliable and can easily used by medical practitioners who are not highly skilled when it comes to handling children as a way of introducing blood products, colloids, medications and crystalloids into the regular circulation (Parthasarathy, 2013) . References Baren, J. M. (2008). Pediatric emergency medicine. Philadelphia: Saunders/Elsevier. Donnelly, L. F. (2009). Fundamentals of pediatric radiology. Philadelphia: Saunders. Parthasarathy, A. (2013). Parthas fundamentals of pediatrics. New Delhi: Jaypee Brothers Publishers. King, C., & Henretig, F. M. (2008). Textbook of pediatric emergency procedures. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins. Taussig, L. M., Landau, L. I., & Le, S. P. N. (2008). Pediatric respiratory medicine. Philadelphia: Mosby/Elsevier. Read More