APLS conference (the rough report).

I have just gotten back from a 2 day instructor conference hosted by APLS Australia.

Advanced Paediatric Life Support (APLS) commenced operations in Australia in 1997. The major focus of APLS is to improve the early management of acutely ill and injured children through the training and education of health professionals.
It also is one of the best structured, intense and well run courses I have ever attended.
Any nurse working with childeren in the hospital setting should be walking over broken glass ampoules to get this one under their professional belt (sign up here).
Here are a spattering of my unedited notes  just to give you a tasting of some of just a few of the topical areas of paediatric life support :

Defibrillation Controversies.

Michael Clifford a paediatric intensivist at Melbourne Childerens hospital gave a talk on some of the changes we may see with upcoming release of the ILCOR 2010 guidelnes.

In a nutshell:

1. Attempt resuscitation. Any attempt is better than no action at all.
2. Protect cardiac compressions. Good technique with minimal interruption.
3. Avoid over ventilation. When ventilating with bag/valve/mask many people tend to bag at their own respiratory rate ( Hypocapnia is bad for your brain.)
4. Attach and use a defibrillator ASAP.

VF in paeds is not uncommon. (Out of hospital arrests in adolescents 15% are VF. In hospital arrests all ages approx 25% are VF)
Primary VF/VT do better than secondary.

Adults mortality increases 7% per minute delay to defibrillation. Early, effectiveand  near continuous chest compressions can attenuate this mortality increase.

Hands free adhesive pads or paddles should be used to minimise the interruption to effective CPR
There is little evidence for the optimum placement of pads or paddles.
When using the anterior pad positioning, having the apical pad running with a horizontal axis and the sternal pad with a vertical one has been shown to decrease transthoracic impaedence.
However, anterior posterior placement remains the placement of choice.

Energy Selection for defibrillation.

4 joules/kg  appears to be a safe and affective initial dose for the treatment of VF/VT.
It remains unclear what the second shock dosing should be, however 6 joules/kg is probably OK.  (Up to 50 joules/kg has been used without any rise in Troponin.)

Continuous CPR through defibrillation.

Stopping CPR prior to defib to perform rhythm analysis, then stating “stand clear”, checking that no-one in the team is in contact with the patient, and charging the defibrillator can all take well over 5 sec.  This  interruption to CPR with a results in a significant drop in the coronary perfusion pressure.
In future ‘Hands on Defibrillation’ protocols will maintain a continued CPR without pause right through the defibrillation.Studies have demonstrated that if the person performing CPR is wearing rubber gloves the actual defibrillation shock will be unperceptable.
Caveat:  Cases have been recorded of resuscitators being shocked by persons who have an implantable defibrillator.

Paediatric cervical spine immobilization.

Ed Oakley, a paediatric emergency physician from Royal Children’s Hospital in Melbourne presented a case study involving his own daughter to emphasize that there remains very limited evidence on the best practice for paediatric c-spine immobilization and clearance, and there is quite a discrepancy between what is taught in many courses and what is actually practiced on the bed.
There is no evidence to support the use of spine boards and strapping other than perhaps pre-hospital management.

Near Drowning.

Dr Anthony Stevenson from Queanbeyan Hospital presented the case of a child who arrived in his ED apnoeic, asystolic and cold (Temp= 26.2 C) 40 minutes after falling into the local river.
Despite a very poor prognosis this child was resuscitated and proceeded to make a full recovery.
[ I have already written about the management of the hypothermic patient.]

Aspiration is nearly universal during drowning (98.6% of patients at autopsy). Patients who have so-called “dry drowning”were probably in respiratory arrest when they hit the water.
Hypoxaemia occurs immediately once as little as 1-2 ml/kg of water enters the lungs. This is usually reversible with ventilation and oxygenation.
Pulmonary oedema develops with both salt and fresh water aspiration.
Of those who die 70% aspirated vomitus, mud, sand or algae. Delayed death is associated with pneumonia, abscesses, mechanical lung injury or alveolar hyaline material at autopsy.

Poor Prognosis (non-icy water)
Submersion > 5-10 minutes.
No CPR > 25 minutes.
Patient requiring CPR at any time once they reach the ED.
Persisting GCS < 3
Abnormal head CT at 36hrs.

Better Prognosis
Immersion < 5-10 minutes.
CPR commenced within 5 minutes of immersion.
Awake and oriented on arrival at ED.
Reactive pupils on arrival at ED ( leads to 100% intact survival).
Improvement of neurological status within hours.

Which interventions help?
Early and effective CPR.
Secure airway.
Oxygenation and circulatory support (consider use of CPAP/BiPaP)
Rewarming of severe hypothermia to 32-34 C.
Achieving normoglycaemia.
Antibiotic therapy if signs of infection or gross contamination.