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Welcome to the lesson on Normal Heart Anatomy for PALS. In this video, we will discuss the normal cardiac anatomy, which will help understand physiology in the next video.

The heart is a hollow muscle comprised of four chambers that are all surrounded by thick walls of tissue called septum. The two upper chambers are the atria, and the two lower chambers are the ventricles.

The right and the left halves of the heart work together to pump blood throughout the body. The right atrium receives blood from the body and sends it to the right ventricle to be sent to the lungs for oxygenation. The left atrium receives the newly oxygenated blood and sends it to the left ventricle ot to be sent throughout the rest of the body.

Valves between each chamber prevent reverse blood flow.

Blood leaves the heart through a large vessel called the aorta. The two atria contract simultaneously, as do the ventricles, making the contractions of the heart go from top to bottom.

Each beat begins in the right atrium. The left ventricle is the largest and has the thickest wall, as it is responsible for pumping the newly oxygenated blood to the rest of the body.

The electrical pathways of the heart begin in the sinoatrial (or SA) node and the right atrium. Together, they create the electrical activity that acts as the heart’s natural pacemaker. This electrical impulse then travels to the atrioventricular (or AV) node, which lies between the atria and the ventricles. After pausing briefly, the electrical impulse moves to the His-Purkinje system, which acts as wiring to conduct the electrical signal into the left and the right ventricles. This electrical signal causes the heart muscle to contract and pump blood.

This concludes the Normal Heart Anatomy for PALS. Next, we will review the Normal Heart Physiology for PALS.

Welcome to the lesson on Normal Heart Physiology for PALS. In this video, we will discuss the normal electrical pathways of the heart.

Understanding the normal electrical function of the heart helps understand the abnormal functions.

When blood enters the atria of the heart, an electrical impulse that is sent from the SA node conducts through the atria, resulting in atrial contraction, which registers as the P wave on an electrocardiogram, or ECG, strip. This impulse then travels to the AV node, which in turn conducts the electrical impulse through the Bundle of His, bundle branches, and the Purkinje fibers of the ventricles causing ventricular contraction.

The time between the start of the atrial contraction and the start of ventricular contraction registers as the PR interval on an ECG strip. The ventricular contraction registers as the QRS complex. Following ventricular contraction, the ventricles rest and repolarize, which registers as the T wave. The atria also repolarize, but this coincides with the QRS complex; therefore, it cannot be observed on the ECG strip.

P wave, QRS complex, and the T wave together at proper intervals are indicative of normal sinus rhythm, or NSR. Abnormalities that are in the conduction system can cause delays in the transmission of the electrical impulse and are detected on the ECG. These deviations from normal conduction can result in dysrhythmias such as heart blocks, pauses, tachycardias and bradycardias, blocks, and dropped beats.

This concludes our lesson on Normal Heart Physiology for PALS. Next, we will review A Systematic Approach.

Welcome to A Systematic Approach. In this lesson, we will discuss the comprehensive approach to take in the event of finding an unresponsive child or infant.

When you find an unresponsive child or infant, it is often possible to immediately deduce the etiology. You should act quickly, decisively, and apply interventions that fit the needs of the individual at that moment.

While there are various ways for a child or an infant to become unresponsive, the central issues that need to be addressed include keeping blood pumping through the vasculature (or perfusion) and supplying oxygen to the lungs (or oxygenation).

When the child or the infant is experiencing poor perfusion and oxygenation, CPR manually takes over for the heart and the lungs. If they are still adequately maintaining perfusion and oxygenation but are unresponsive, then rapid diagnosis and treatment may be possible without CPR.

It is important to differentiate normal breathing from gasping or agonal breathing. Gasping is considered ineffective breathing.

Similarly, not all pulses are adequate. The rule of thumb is that at least 60 beats per minute is required to maintain adequate perfusion in a child or an infant.

The assessment must be carried out quickly. There is a low threshold for administering ventilation and/or compressions if there is evidence that the child or the infant cannot do either effectively on their own.

If the problem is respiratory in nature, then initiation of rescue breathing is warranted. If breathing is ineffective and pulses are inadequate, begin high-quality CPR immediately. It is important to understand that any case can change at any time, so you must reevaluate periodically and adjust the approach to treatment accordingly.

Use CPR to support breathing and circulation until the cause has been identified and effectively treated.

This concludes our lesson on A Systematic Approach. Next, we will review Initial Diagnosis and Treatment.

Welcome to the lesson on Initial Diagnosis and Treatment. In this video, we will consider the scenario of when the child or infant is not in immediate danger and briefly discuss the ABCDE method.

If you have reached the Initial Diagnosis and Treatment phase of care, the child or infant is not in immediate danger of death. While this means that you have a brief moment to find the cause of the problem and intervene with appropriate treatment, it does not mean that a life-threatening event is impossible.

In this case, always be vigilant for any indication to initiate high-quality CPR and look for life-threatening events such as respiratory distress, a change in consciousness, or cyanosis.

The AHA recommends following the ABCDE method when reaching Initial Diagnosis and Treatment phase. The ABCDE method consists of checking for Airway, Breathing, Circulation, Disability, and Exposure.

This concludes our lesson on Initial Diagnosis and Treatment. Next, we will go in-depth to review each of the ABCDE method components.

Welcome to the lesson on Airway. In this video, we will discuss how to assess the child or the infant’s airway.

When assessing airway, you should determine of one of the three possibilities:

If the airway is open and unobstructed, then move on to Breathing.
If the airway cannot be kept open manually, then use the head-tilt-chin-lift maneuver, the jaw-thrust maneuver, or the basic airway adjuncts like naso-pharyngeal (naso-fir-in-ge-al and oropharyngeal (or-rof-er-ren-ge-al).
If an advanced airway is required, then use endotracheal intubation or cricothyrotomy (crik-o-thy-rotomy).

Once an airway has been established and maintained, then move on to Breathing.

This concludes our lesson on Airway. Next, we will review Breathing.

Welcome to the lesson on Breathing. In this video, we will discuss how to assess the child or the infant’s breathing.

If the child or infant is not breathing effectively, it is a life-threatening event, and you should treat it as a respiratory arrest. However, if it’s abnormal yet marginally effective breathing, it can be assessed and managed by determining the breathing being too fast or too slow.

Tachypnea (tack-ip-knee-a), or abnormally fast breathing, has an extensive differential diagnosis while bradypnea (brad-dip-knee-a), or abnormally slow breathing, can be a sign of impending respiratory arrest.

To assess effective breathing, you should also check for increased respiratory effort. Signs of increased respiratory effort include nasal flaring, rapid breathing, chest retractions, abdominal breathing, stridor, grunting, wheezing, and crackles.

This concludes our lesson on Breathing. Next, we will review Circulation.

Welcome to the lesson on Circulation. In this video, we will discuss how to assess the child or the infant’s circulation.

Assessment of circulation in pediatrics involves more than checking the pulse and blood pressure.

The color and temperature of the skin and mucous membranes can help to assess effective circulation. Pale or blue skin indicates poor tissue perfusion.

Capillary refill time is also a useful assessment in pediatrics. Adequately, perfused skin will rapidly refill with blood after it is squeezed (for example, by bending the tip of the finger at the nail bed). Inadequately perfused tissues will take longer than two seconds to respond.

Abnormally, cool skin can also suggest poor circulation.

The normal heart rate and blood pressure in pediatrics are quite different than in adults and change with age. Likewise, heart rates are slower when children and infants are asleep. Most centers will have acceptable ranges that they use for normal and abnormal heart rates for a given age. While you should follow your local guidelines, approximate ranges are listed in Table 5 in your corresponding PALS manual.

This concludes our lesson on Circulation. Next, we will review Disability.

Welcome to the lesson on Disability. In this video, we will discuss how to assess the child or the infant’s disability.

In PALS, disability refers to performing a rapid neurological assessment. A great deal of information can be gained from determining the level of consciousness on a four-level scale. Pupillary response to light is also a fast and useful way to assess neurological function.

Neurologic assessments include AVPU (that is alert, voice, pain, unresponsive) response scale and the Glasgow Coma Scale (or GSC GCS). A specially-modified GCS is used for children and infants and takes developmental differences into account.

Refer to Tables 6 and 7 in your corresponding PALS manual for AVPU Response Scale and the GSC, respectively.

This concludes our lesson on Disability. Next, we will review Exposure.

Welcome to the lesson on Exposure. In this video, we will discuss how to assess the child or the infant’s Exposure.

Exposure is classically most important when you are responding to a child or infant who may have experienced trauma. However, it has a place in PALS evaluations.

Exposure reminds the provider to look for signs of trauma, burns, fractures, and any other obvious sign that might provide a clue as to the cause of the current problem.

Skin temperature and color can provide information about the child or infant’s cardiovascular system, tissue perfusion, and mechanism of injury.

If time allows, the PALS provider can look for more subtle signs such as petechiae or bruising.

Exposure also reminds the provider that children and infants lose core body temperature faster than adults do. Therefore, while it is important to evaluate the entire body, be sure to cover and warm the individual after the diagnostic survey.

This concludes our lesson on Exposure. Next, we will review the Secondary Diagnosis and Treatment.

Welcome to the lesson on Secondary Diagnosis and Treatment. In this video, we will discuss a more thorough survey of the brief ABCDE.

The secondary diagnosis includes focused history and physical examination involving the person, the person’s family, and any witnesses. In terms of history, follow the acronym SPAM, which stands for Signs and symptoms, Past medical history, Allergies, and Medications. For details on what to check during SPAM evaluation, refer to Table 8 in the corresponding PALS manual.

The focused examination is guided by the answers to the focused history. For example, a report of difficult breathing will prompt a thorough airway and lung examination. It may also prompt a portable chest x-ray study in a hospital setting. The key point is that it is best to work from head to toe to complete a comprehensive survey. Make use of diagnostic tools when possible to augment physical examination.

This concludes our lesson on Secondary Diagnosis and Treatment. Next, we will review Life-Threatening Issues.

Welcome to the lesson on Life-Threatening Issues. In this video, we will discuss what to do during a life-threatening emergency.

If at any time you determine that the child or infant is experiencing a life-threatening emergency, support breathing, and cardiovascular function immediately. This usually means providing high-quality CPR.

While it is important to recognize and respond to the particular cause of the problem, the time required to determine the problem should not interfere with perfusion and oxygenation for the child or the infant. As you maintain breathing and circulation for them, determine if they are primarily experiencing respiratory distress or arrest, bradycardia, tachycardia, shock, or cardiac arrest.

Individual PALS protocols for each of these clinical situations are provided throughout the videos and corresponding PALS manual.

This concludes our lesson on Life-Threatening Issues. Next, we will review Resuscitation Tools.