APLS 4th Edition

Basic Life Support

Assessment:

• Assess airway - obstruction visible?
• Assess breathing: effort, noises inc grunt, chest expansion, sats. Note effect of breathing on other systems- HR, colour, mental status.
• These criteria are not valid where there is exhaustion, or neurological disease affecting breathing.
• Assess circulation: HR, perfusion inc temp, BP. Note effect on other systems- RR, urine, mental status
• Assess neuro: AVPU, pupils

BLS:

• start compressions if unsure & no responses eg gag/cough or movement.
• Chest expansion is the only direct test of ventilation.

Choking:

• Effective cough? Then observe. Unconscious? Usual BLS. Else 5 back blows then 5 chest compressions (slow, forceful)(infant), 5 abdo thrusts (child) then assess.

Adjuncts

Airway:

• Infant - tongue depressor or laryngscope to insert, right way up.
• ETT position: look, listen in axillary line & over stomach, etCO2 (except cardiac arrest)

Circulation:

• 4Hs &4Ts:
• hypoxia, hypovolaemia, hypo/hyperkalaemia/metabolic, hypothermia.
• Tension pneumo, tamponade, toxic, thromboembolic.
• Also consider bicarb.
• At 2min reassessment of monitor, 4min adrenaline (10mcg/kg)

Shockable?

• Single shocks of 4J/kg straight into CPR
• At 3rd shock give adrenaline
• At 4th give amiodarone 5mg/kg

AED (Automated emergency defibrillator) - give attenuated shock for 1-8yr, adult shock for >8yr

Don't forget Glucose

Arrhythmias

Brady: atrop 20mcg/kg if evidence of vagal, then adrenaline bolus, then infuse or pace

SVT: esp HR>200-220. If shocked vagal only while getting defib and iv access. Whichever comes first.

Neuro

Pupils:

• small: Metabolic disorder, organophosphate poisoning, medullary lesion
• dilated: Barbit urate poisoning, post seizure, anticholinergic drugs, hypothermia
• Unilateral dilated pupil: focal seizure, herniation

Seizure

Buccal midazolam dose = 0.5mg/kg

10min steps

Lorazepam has longer half life, less resp depression than diazepam

Still give loraz after PR/buccal once IV access obtained

Trauma

Bolus 10ml/kg, 10 then call surgeon, further 10 +10, then blood

Takes 10min to get group specific

Differences in ABC:

• B- looking for dangerous chest injuries, C-haemorrhage, E- log roll (remove spinal board), temperature

Do bloods incl amylase

XRs - Cervical spine AP/lat/odontoid

Analgesia: 0.1mg/kg unless reduced GCS or shock (0.05), else Entonox (CI: basal skull #, pneumoth)

Take a history

Secondary survey- top to toe & back, inspect/palpate/neuro

• Basal skull #: blood/CSF from nose/ears (haemotympanum), raccoon eyes, Battle's sign
• ATOMFC for dangerous chest injuries: airway, tension (surgical emphysema, tracheal deviation), open pneumo (sucking), massive haemothorax (dullness), flail chest (crepitus), cardiac tamponade (muffled sounds)
• Abdom: ngt (beware basal skull #), urinary catheter (beware blood @meatus, bruising @perineum), rectal (anal tone)

Abdo uss quick, but single contrast CT is investigation of choice.

Diagnostic peritoneal lavage (DPL) only for rewarming & dialysis!

Theatre for penetrating, perforation, fluid replacement >40ml/kg

Non-operative mx appropriate for solid organ trauma if close monitoring, precise fluid mx, immediate surgical availability. NB coagulopathy

Cx spine clearing: normal xr/ct, no pain or tenderness, no neuro signs, FROM without pain. Hard collar & manual inline stabilization only if combative.

Final step is Transfer to definitive care facility

Head injury

Secondary brain injury: hypoxia, hypotension, RICP, seizures

NB potential for major blood loss from intracranial or scalp inj in infants

GCS applied to <4yr: usual verbal ability, reduced +/or spont irritable cry, inappropriate cry!, occ whimper.

Indications for head CT:

• GCS<13, or <15@2hrs,
• suspected # (depressed, basal skull),
• focal neuro,
• >1x vomit (>2 in under12yr),
• signif mech (eg fall >2x patient height), retrograde amnesia >30mins,
• seizure,
• coagulopathy,
• falling GCS,
• amnesia

?include cx spine. SXR for NAI.

Limb trauma

Amputation: elevation, local pressure, fluids. Else arterial compression, elastic compression bandage (NOT tourniquet)

Compartment syndrome: pain on passive stretching, reduced sensation, pale, paralysed, pulseless (late)

Burns

Parkland formula:

• Wt x percentage x4 over 24hr from burn time
• Plus maintenance
• Give 1/2 in first 8hr
• Reassess according to urine output

Partial: pink/patchy/blistered. Full: White/charred/leathery

Sterile towels or cling film

Cold irrigation only for partial up to 10pc for up to 10min

Electrical: v high voltage can arc causing flash burns without deep injury! Identify entry/exit points, beware late dysrhythmia, aggressive rx of myoglobinuria (2ml/kg urine, bicarb)

Drowning: protect vs aspiration with ETT&NG. Rewarm IV@39, everywhere else 42degC (ng, bladder, airway, pleural, peritoneala- ?ecmo). 1deg per hr. hypothermia predisposes to VF - give initial shock but then defer until 30degC. Defer resus drugs until 30degC.

• Return of spont resp at 3mins good prog,
• no response at 40min poor unless hypothermia or intox,
• immersion >8min poor,
• pH<7 and pO2<8 persistently, poor.

Other

Needle crico preferred <12yr. Either needle or surgical in older

Pseudo Sublux: 3-4yr, ant body line discontinuous at C2/3, 3/4 but post lines normal. Rpt avoiding flexion

Cxr: remember mediastinum, spine

NLS

• Clamp + cut
• Dry + stimulate
• THEN assess breathing, colour, HR, tone
• Initial slow inflation breaths x5
• then 30sec ventilation
• Cardiac compressions if HR not rising - 3:1