PALS (Pediatric Advanced Life Support)

Pediatric Life Support
Oleh: dr. Ayyesha Yuanita

Pembimbing : dr. Dwi Purnomo Sidhi, Sp. A
dr. Huluwiyah, Sp. An
dr. Ani Pujiningrum MMKes
American Heart Association
Pediatric Advanced Life Support
Guidelines first published in 1997
Revisions made in 2005
Revisions made in 2010
EPIDEMIOLOGI
Outcome in-hospital CPR
Reis, et al. 2002. A Prospective

Investigation Into the Epidemiology
of In Hospital Pediatric
Cardiopulmonary Resuscitation
Using the International Utstein
Reporting Style. PEDIATRICS Vol.
Penyebab Henti Jantung
dan Bradikardia
Reis, et al. 2002. A Prospective

Investigation Into the Epidemiology
of In Hospital Pediatric
Cardiopulmonary Resuscitation
Using the International Utstein
Reporting Style. PEDIATRICS Vol.
In contrast to adults, cardiac arrest in
infants and children does not usually result
from a primary cardiac cause. More often it
is the terminal result of progressive
respiratory failure or shock, also called an
asphyxial arrest.
Asphyxia begins with a variable period of
systemic hypoxemia, hypercapnea, and
acidosis, progresses to bradycardia and
hypotension, and culminates with cardiac
arrest.
Kleinman, et al. 2010. Part 14: Pediatric
Advanced Life Support 2010 American Heart
Association Guidelines for Cardiopulmonary
Resuscitation and Emergency Cardiovascular
Care. Downloaded from
PENYEBAB HENTI JANTUNG
KEHILANGAN MALDISTRIBUSI DISTRES DEPRESI

CAIRAN CAIRAN PERNAPASAN PERNAPASAN
PERDARAHAN SYOK SEPTIK ASPIRASI KEJANG

GE PENY.JANTUNG ASMA TIK
LUKA BAKAR ANAFILAKSIS BP KERACUNAN
GAGAL SIRKULASI GAGAL NAPAS
Hipoksia
GAGAL KARDIOPULMONAL Hiperkapneu
Asidosis
Bradikardia
HENTI JANTUNG Hipotensi
8
VENTILASI OKSIGEN
YANG TIDAK YANG TIDAK
ADEKUAT CUKUP
GAGAL NAPAS
1. RR meningkat + tanda distres nafas (pch,

retraksi, pernafasan seesaw, atau merintih)
2. Usaha nafas yang tidak adekuat misalnya
suara nafas yang berkurang atau gasping,
terutama jika disertai penurunan kesadaran
3. Sianosis dengan nafas yang tidak normal
meskipun sudah diberi oksigen
KETIDAKMAMPUAN
ALIRAN DARAH +
OKSIGEN SAMPAI
PADA JARINGAN
SYOK
TIDAK
TERKOMPENSASI
TERKOMPENSASI
Nadi Penurunan kesadaran
Akral dingin dan PU
pucat Asidosis metabolik
CRT > 2 dtk RR
Nadi perifer Nadi sentral melemah
melemah Perubahan warna kulit
Tekanan darah (ex: mottling)
sistolik normal
Hypotension is defined as a Systolic blood
pressure:
60 mm Hg in term neonates (0 to 28 days)

70 mm Hg in infants (1 month to 12 months)
70 mm Hg + (2xage in years) in children 1
to 10 years
90 mm Hg in children 10 years of age

ABC
BLS OR
CAB?
2010 AHA for CPR recommend a CAB
sequence
Chest compression
Airway
Breathing
Ventilation
PENOLONG AWAM
BLS TENAGA MEDIS ATAU

PENOLONG YANG
SUDAH TERLATIH
PENOLONG AWAM UNRESPONSIVE
+ TDK
BERNAFAS
Safety of Rescuer and Victim Atau GASPING
Assess Need for CPR

CPR 30x
1. Check for Response Nafas buatan 2x
2. Check for Breathing
3. Start Chest Compressions Lakukan selama
2 menit (5
4. Open the Airway and Give Ventilations
siklus)
5. Coordinate Chest Compressions and Breathing
. Activate Emergency Response System
Panggil
Bantuan
Berg, et al. 2010. Part 14: Pediatric Advanced

LifeSupport 2010 American Heart Association
Guidelines for Cardiopulmonary Resuscitation
and Emergency Cardiovascular Care.
Chest Compression
Push fast ( 100x per menit)

Push hard ( 1/3 diameter AP thoraks atau 4
cm pada bayi, 5 cm pada anak-anak)
Chest recoil
Minimize interruptions
Avoid excessive ventilation
Bayi: Anak:
Dengan 2 jari 1 atau 2 tangan
di bawah di separuh
intermammary sternum bagian
Berg, et al. 2010. Part 14: Pediatric Advanced line bawah
Two-finger chest compression technique in infant (1
rescuer).
Airway and Ventilation
Buka jalan nafas dengan head tilt-chin lift

Bayi: mouth-to-mouth-and-nose
Anak-anak: mouth-to-mouth
Sampai dada terangkat
Setiap bantuan nafas cukup 1 detik

TENAGA MEDIS ATAU PENOLONG
YANG SUDAH TERLATIH
Assess the Need for Defibrillation (BOX 6)
CPR (BOX 1) Defibrillation Sequence
Pulse Check (BOX 3) Using an AED
Hands-Only
Inadequate Breathing
(Compression-Only)
With Pulse (BOX 3A)
CPR
Bradycardia With Poor Breathing Adjuncts
Perfusion (BOX 3A)
Chest Compressions
(BOX 4)
Ventilations (BOX 4)
Coordinate Chest
Compressions and
Ventilations

Inadequate
Brachial breathing with
(infant) pulse (60),
Carotid or
Bradycardia
femoral (child)
(pulse<60) with
poor perfusion
(pallor, mottling,
cy cyanosis)
despite support
O2 and
2-finger ventilation
2-thumb-
encircling
Initial dose: 2J/kg

Second dose:
4J/kg
Two thumb-encircling hands chest compression in infant
(2 rescuers)
The EC clamp technique of bag-mask ventilations.
Three
fingers of one hand lift the jaw (they form the E) while
the thumb
and index finger hold the mask to the face (making a
C).
The Quality of BLS
Immediate CPR can improve survival from

cardiac arrest in children, but not enough
children receive high-quality CPR. We must
increase the number of laypersons who
learn, remember, and perform CPR, and
must improve the quality of CPR provided
by lay rescuers and healthcare providers
alike.

APLS AHA
2010
BLS Considerations During
PALS
Pediatric advanced life support (PALS) usually takes place
in the setting of an organized response in an advanced
healthcare environment. In these circumstances, multiple
responders are rapidly mobilized and are capable of
simultaneous coordinated action. Resuscitation teams
may also have access to invasive patient monitoring that
may provide additional information during the
performance of basic life support (BLS).
BLS (whether for a child or adult) is presented as a series
of sequential events with the assumption that there is
only one responder, but PALS usually takes place in an
environment where many rescuers are rapidly mobilized
and actions are performed simultaneously.

Airway
Oropharyngeal and Nasopharyngeal

Airway
Laryngeal Mask Airway (LMA)
Bag-Mask Ventilation
Endotracheal Tube
Oxygen
Pulse oximetry
Gastric Inflation
Suction Device
Oropharyngeal Airway
Pasien tidak sadar (refleks muntah -)
Perhatikan ukuran dengan benar!
SIZE PROPER POSITION

Nasopharyngeal Airway
Refleks muntah +
Perhatikan ukuran diameter dan panjangnya!
Bag-Mask Ventilation
ONE
PERSON
2-PERSON
Use only the force and tidal volume needed to
just make the chest rise visibly (Class I, LOE C);
avoid delivering excessive ventilation during
cardiac arrest (Class III, LOE C)
Excessive ventilation during cardiac arrest
increases intrathoracic pressure, which impedes
venous return, thus reducing cardiac output and
cerebral and coronary blood flow. These effects
will reduce the likelihood of ROSC.
In addition, excessive ventilation may cause air
trapping and barotrauma in patients with small
airway obstruction. It also increases the risk of
stomach inflation, regurgitation, and aspiration.

Endotracheal Tube
1. Cricoid Pressure During
Intubation
2. Endotracheal Tube Size
3. Verification of Endotracheal
Tube Placement
Requires
special
training
Cricoid Pressure During
Intubation
There is insufficient evidence to
recommend routine cricoid pressure
application to prevent aspiration during
endotracheal intubation in children. Do not
continue cricoid pressure if it interferes
with ventilation or the speed or ease of
intubation (Class III, LOE C).

Endotracheal Tube Size
Cuffed
0-1 tahun: 3,5 mm
1-2 tahun: 4 mm
2 tahun: 4+(age/4)
mm
Uncuffed
(-) 0,5 cuffed
Verification of Endotracheal
Tube Placement
Look for bilateral chest movement and listen for equal
breath sounds over both lung fields, especially over
the axillae.
Listen for gastric insufflation sounds over the stomach.
They should not be present if the tube is in the
trachea.
Check for exhaled CO2 (see Exhaled or End-Tidal CO2
Monitoring, below).
If there is a perfusing rhythm, check oxyhemoglobin
saturation with a pulse oximeter. Remember that
following hyperoxygenation, the oxyhemoglobin
saturation detected by pulse oximetry may not decline
for as long as 3 minutes even without effective
ventilation.
If you are still uncertain, perform direct laryngoscopy
and visualize the endotracheal tube to confirm that it
Kleinman, et al. 2010
lies between the vocal cords.
If an intubated patients condition
deteriorates, consider the following
possibilities (mnemonic DOPE):
Displacement of the tube
Obstruction of the tube
Pneumothorax
Equipment failure
Jika tidak terintubasi Jika terintubasi
Beri bantuan nafas
1 penolong2
setiap 6-8 detik (8-10
bantuan nafas setiap
kali permenit) tanpa
30 kali pijat jantung
menginterupsi pijat
2 penolong2
jantung
bantuan nafas setiap
15 kali pijat jantung
Jika pasien tidak ada tanda syok namun tidak bernafas atau
nafas tidak adekuat beri nafas bantuan setiap 3-5 detik (12-20
nafas permenit)
KEMPUT-LEPAS-LEPAS
Oxygen Pulse Oximetry Gastric Suction device
Inflation
Saturasi Bisa tidak akurat Dapat Jangan
94% pada pasien menyebabkan memasukkan
dengan perfusi regurgitasi dan selang suction
perifer yang jelek, aspirasi. Dapat terlalu dalam
keracunan karbon diminimalisir sampai melebihi
monoksida atau dengan cara: ETT karena
methemoglobinem 1.Hindari dapat melukai
ia tekanan mukosa.
inspirasi yg Gunakan
berlebihan kekuatan
dengan maksimum -80
memberikan s/d -120 mmHg
secara pelan
sesuai volume
tidal sampai
dada
mengembang
2.Memberikan
tekanan pada
cricoid
3.Memasang
nasogastric
Vascular Access
IO
Emergency Medications
Adenosine
Amiodaron Epinefrine
Atropine Lidocaine
Calcium Glucose
Procainamide Magnesium
Sodium
bicarbonate
Adenosine
Adenosine causes a temporary

atrioventricular (AV) nodal conduction
block and interrupts reentry circuits that
involve the AV node. The drug has a wide
safety margin because of its short half-life.

Amiodarone
Amiodarone slows AV conduction, prolongs

the AV refractory period and QT interval,
and slows ventricular conduction(widens
the QRS).

Atropine sulfate
Atropine sulfate is a parasympatholytic

drug that accelerates sinus or atrial
pacemakers and increases the speed of AV
conduction.

Calcium
Calcium administration is not

recommended for pediatric
cardiopulmonary arrest in the absence of
documented hypocalcemia, calcium
channel blocker overdose,
hypermagnesemia, or hyperkalemia (Class
III, LOE B).
Routine calcium administration in cardiac
arrest provides no benefit and may be
harmful.
Epinephrine
The alfa-adrenergic-mediated vasoconstriction of
epinephrine increases aortic diastolic pressure
and thus coronary perfusion pressure, a critical
determinant of successful resuscitation from
cardiac arrest. At low doses, the beta-adrenergic
effects may predominate, leading to decreased
systemic vascular resistance; in the doses used
during cardiac arrest, the vasoconstrictive alfa-
effects predominate.

Glucose
Because infants have a relatively high glucose
requirement and low glycogen stores, they may
develop hypoglycemia when energy requirements
rise. Check blood glucose concentration during
the resuscitation and treat hypoglycemia
promptly (Class I, LOE C)

Magnesium
Magnesium is indicated for the treatment

of documented hypomagnesemia or for
torsades de pointes (polymorphic VT
associated with long QT interval).
Magnesium produces vasodilation and
may cause hypotension if administered
rapidly.

Procainamide
Procainamide prolongs the refractory

period of the atria and ventricles and
depresses conduction velocity.

Sodium Bicarbonate
Routine administration of sodium

bicarbonate is not recommended in
cardiac arrest (Class III, LOE B).
Excessive sodium bicarbonate may impair
tissue oxygen delivery; cause
hypokalemia, hypocalcemia,
hypernatremia, and hyperosmolality;
decrease the VF threshold; and impair
cardiac function.
Lidocaine
Lidocaine decreases automaticity and

suppresses ventricular arrhythmias, but is
not as effective as amiodarone for
improving ROSC or survival to hospital
admission among adult patients with VF
refractory to shocks and epinephrine.

Defibrillators
Manual
Defibrillators
Paddle size
PULSELESS ARREST
Unresponsive + no
breathing
2 J/kg
4 J/kg
Or Lidocaine
Bolus: 1 mg/kg
IV/IO
4-10
J/kg
If defibrillation is
successful but VF recurs,
resume CPR and give
another bolus of
amiodarone before trying
to defibrillate with the
previously successful
shock dose.
Torsades de Pointes
This polymorphic VT is associated with a long QT

interval, which may be congenital or may result
from toxicity with type IA antiarrhythmics (eg,
procainamide, quinidine, and disopyramide) or
type III antiarrhythmics (eg, sotalol and
amiodarone), tricyclic antidepressants, digitalis,
or drug interactions.
Torsades de pointes VT typically deteriorates
rapidly to VF or pulseless VT, so providers should
initiate CPR and proceed with defibrillation when
pulseless arrest develops. Regardless of the
cause, treat torsades de pointes with a rapid
(over several minutes) IV infusion
Kleinman, et of magnesium
al. 2010
Bradycardia
Pacing maybe life
saving on
complete HB and
sinus node
dysfunction
Pacing not useful
on asystole and
ische
mia myocardial Selama 2
menit
Tachycardia
Sinus takikardia
SVT
Do not use
adenosine in
WPW synd
Pijat karotis
Valsava
manouver
Apply ice to the
face
or Verapamil 0.1-0.3
mg/kg
If second shock unsuccessful or tachycardia recurs
quickly, consider amiodarone or procainamide before
Special Resuscitation
Situations
Septic Shock
Use isotonic crystalloid solution as the

initial fluid for the treatment of septic
shock (Class IIa, LOE C)
Early assisted ventilation may be
considered as part of a protocol-driven
strategy for septic shock (Class IIb, LOE C)

Hypovolemic Shock
Use an isotonic crystalloid solution (eg,

lactated Ringers solution or normal saline)
as the initial fluid for the treatment of
shock (Class I, LOE A)
Treat signs of shock with a bolus of 20
mL/kg of isotonic crystalloid even if blood
pressure is normal (Class IIb, LOE C). Give
additional boluses (20 mL/kg) if systemic
perfusion fails to improve.
Termination of Resuscitative
Efforts
There are no reliable predictors of
outcome to guide when to terminate
resuscitative efforts in children.
Clinical variables associated with survival
include length of CPR, number of doses of
epinephrine, age, witnessed versus
unwitnessed cardiac arrest, and the first
and subsequent rhythm.

Pembahasan Khasus
Pukul Dr. Jaga Melakukan Didapatka Oksigen
02.30 UGD PAT n masker 10
dikonsulka Penampila kemungkin lpm,
n pasien n: tonus an anak nebule PZ,
ruangan lemah, mengalami suction
anak interaktifit distress
dengan as (-) nafas Unresponsive
Panggil bantuan, +
tidak sadar Upaya
pasang
+ riwayat nafas: gasping
defibrilator
DADRS merintih,
retraksi
Cek nadi 10 dtk
(+)
Sirkulasi
kulit: CPR
sianosis
(+)
Defibrilator
Pukul Kondisi Melakukan Didapatka Oksigen
terpasang cek
02.45 pasien primary n anak ambu bag
irama
tidak survey mengalami 10 lpm +
membaik A: bebas distress assist
B: RR nafas
52x/m, rh
+/+
C: sianosis,
Pukul Anak Saturasi Stesolid 5
02.50 mengalami semakin mg supp
kejang menurun,
bradikardia
Pukul Konsul SpO2: Gagal RJPO
03.00 anestesi 43% kardiopulm
N: 43 x/m onal
(oxymetri)
Pukul Dr RJPO +
03.10 anestesi intubasi
datang
Pukul Pasien RJPO
04.50 tidak ROSC dihentikan

PALS (Pediatric Advanced Life Support)

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Pediatric Life Support

Oleh: dr. Ayyesha Yuanita

Reis, et al. 2002. A Prospective

Reis, et al. 2002. A Prospective

KEHILANGAN MALDISTRIBUSI DISTRES DEPRESI

PERDARAHAN SYOK SEPTIK ASPIRASI KEJANG

GAGAL SIRKULASI GAGAL NAPAS

1. RR meningkat + tanda distres nafas (pch,

60 mm Hg in term neonates (0 to 28 days)

Kleinman, et al. 2010. Part 14: Pediatric

BLS TENAGA MEDIS ATAU

Assess Need for CPR

Berg, et al. 2010. Part 14: Pediatric Advanced

Push fast ( 100x per menit)

Buka jalan nafas dengan head tilt-chin lift

Berg, et al. 2010. Part 14: Pediatric Advanced

Berg, et al. 2010. Part 14: Pediatric Advanced

Initial dose: 2J/kg

Immediate CPR can improve survival from

Berg, et al. 2010. Part 14: Pediatric Advanced

Kleinman, et al. 2010. Part 14: Pediatric

Oropharyngeal and Nasopharyngeal

SIZE PROPER POSITION

Kleinman, et al. 2010. Part 14: Pediatric

Kleinman, et al. 2010. Part 14: Pediatric

Adenosine causes a temporary

Kleinman, et al. 2010. Part 14: Pediatric

Amiodarone slows AV conduction, prolongs

Kleinman, et al. 2010. Part 14: Pediatric

Atropine sulfate is a parasympatholytic

Kleinman, et al. 2010. Part 14: Pediatric

Calcium administration is not

Kleinman, et al. 2010. Part 14: Pediatric

Kleinman, et al. 2010. Part 14: Pediatric

Magnesium is indicated for the treatment

Kleinman, et al. 2010. Part 14: Pediatric

Procainamide prolongs the refractory

Kleinman, et al. 2010. Part 14: Pediatric

Routine administration of sodium

Lidocaine decreases automaticity and

Kleinman, et al. 2010. Part 14: Pediatric

This polymorphic VT is associated with a long QT

Use isotonic crystalloid solution as the

Kleinman, et al. 2010. Part 14: Pediatric

Use an isotonic crystalloid solution (eg,

Kleinman, et al. 2010. Part 14: Pediatric

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