A 4-year-old girl presents to the ED after being struck by a vehicle while riding her bike. She was awake and complaining of neck pain immediately after the accident but is somnolent with sonorous respirations on your examination in the ED. Her oxygen saturation is 89% and her heart rate (HR) is 50 beats/min. According to the Pediatric Acute Life Support guidelines,
what are the MOST appropriate initial steps in assessment and management for this patient?
A. First impression; cardiopulmonary resuscitation (CPR)Correct Answer: A
Pediatric Advanced Life Support (PALS), similar to both ACLS and advanced trauma life support (ATLS), follows a systematic approach. First Impression followed by evaluate-identify-intervene (which includes primary assessment, secondary assessment, and diagnostic tests) constitutes the steps in the PALS algorithm. The algorithm starts with a first impression to help determine whether or not the patient is in imminent danger, either of cardiac or respiratory failure. Patients who are conscious or unconscious, but breathing can progress to the evaluate-identify-intervene step in the algorithm. Patients who are not breathing adequately but have a pulse greater than 60 beats/min should undergo rescue breathing. Patients with a pulse less than 60 beats/min should undergo CPR.
The second step of the algorithm is evaluate-identify-intervene. This is an ongoing cycle, in which the clinician is repeatedly reevaluating the patient and performing interventions based on the findings. Throughout the process, if the patient stops breathing or has a pulse less than 60 beats/min, then the clinician should begin rescue breathing or CPR, respectively. If the patient remains breathing and has a pulse greater than 60 beats/min, then the clinician should progress to the next steps in the algorithm.
Evaluate-identify-intervene are components of the primary assessment and secondary assessment, and guide the choice of diagnostic testing. The primary assessment follows the primary survey in ATLS: Airway, Breathing, Circulation, Disability, Exposure. An oxygen saturation that is less than 90% indicates that respiratory support is needed. In the pediatric patient population, a heart rate less than 60 beats/min suggests cardiac failure, and CPR should be initiated.
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