Advanced Paediatric Life Support Welkom Read the notes under the slides NB check video links working and adjust sound as appropriate to environment

APLS: Leerdoelen het voorzien van kennis voor de opvang en stabilisatie van kinderen met levensbedreigende aandoeningen het aanleren van de praktische procedures die hierbij nodig zijn deze vaardigheden en hun toepassing ervan worden continu geëvalueerd Stop om 9u15

APLS: Inhoud Theorie Manual en VLE Praktijk Vaardigheidsstations, workshops Simulatietrainingen Beoordeling Pre-cursus: VLE Tijdens cursus: continue evaluatie Cursus Opvang van ernstig zieke kinderen Opvang van zwaargewonde kinderen Reanimatie van kinderen Candidates will be assessed during skill stations, workshops and simulations on their knowledge/skills as well as their performance working either within a team, or as a team leader. They will also be assessed for their potential as future instructors, based on their enthusiasm, support of colleagues, team-working, communication skills and credibility.

APLS: jouw rol Je zou: het boek moeten gelezen hebben de VLE met al zijn vragen achter de rug moeten hebben alle sessies moeten bijwonen je zelfreflectie tijdens de cursus goed moeten bijhouden je medekandidaten en faculty enthousiast ondersteunen maar vooral: veel plezier moeten hebben! Candidates should be informed that they will be assessed in simulations on both technical and non-technical skills, but also when observing and debriefing. Reflective log: Candidates can access electronic copy on VLE / paper copy on course Capture reflections during the course that you can then utilise in the clinical environment Time at end of day 2 to share your experiences and implementation of the APLS approaches in practice

Simulaties Je bent wie je bent Iedereen start op als leider, in het begin met een team van 2 personen. Na het vervolledigen van de initiele evaluatie en resuscitatie komt het 2e team toe. Dan werk je verder als team, je kan de leiding behouden of overdragen. Debriefing van technische maar ook niet-technische vaardigheden (human factors)

APLS: ondersteuning Mentor FACULTY VOORSTELLEN Feedback This would be a nice time to introduce (SHORT!) the faculty and they can each mention whose mentor and group they are. Feedback here relates to that which candidates receive during the course

APLS: na de cursus 4 j toegang tot de site/VLE: Referenties, BestBETs, Richtlijnen Updates, e-Scenarios Online onderwijskundige bronnen Feedback: Post-cursus vragenlijst invullen op de VLE Zelf certificaat downloaden Tweet op #apls INSTRUCTOR NOTES eScenarios for CPD are available on the ALSG web-site. Successful completion of five of these is awarded one CPD point from the RCPCH. Past e-scenarios continue to be available and instructors are encouraged to contribute to the development of new ones.

Advanced Paediatric Life Support not Mention any local fire regulations and to turn off mobile phones. Introductie en huisregels Advanced Paediatric Life Support

Herkenning en opvang van ernstig zieke kinderen Advanced Paediatric Life Support Herkenning en opvang van ernstig zieke kinderen

Ernstig ziek kind: leerdoelen een snelle klinische beoordeling kunnen uitvoeren om de ernst van ziekte bij het kind in te schatten de gestructureerde aanpak leren voor het behandelen van ernstig zieke kinderen Structured approach is needed in the simulations The rapid clinical assessment should take less than 60s (excl BP) – it follows the same order as treatment should be provided Re-assessment using the same structure should be undertaken after any treatment It is used as a communication tool between staff and for record keeping in the critically ill or injured child

Oorzaken van hartstilstand bij kinderen Luchtweg- obstructie Respiratoire depressie Alveolair/thorax-wand falen Vochtverlies Vocht- maldistributie Hartfalen Vreemd voorwerp, astma, valse kroep, bronchiolitis Respiratoir Falen Hartstilstand Circulatoir Falen Convulsies, sepsis, intoxicatie, ↑ICP Pneumonie, thorax- trauma & spierziekte Bloeding, brandwonde, diarrhee, braken Sepsis, anafylaxie cardiomyopathie, congenitale afwijking Talk about how assessment and intervention with the conditions on the left of the slide can prevent or slow progression to the serious consequences on the right of the slide. This involves rapid assessment of the seriously ill child (summarised on next slide). Examples: Respiratory obstruction: croup, asthma, bronchiolitis// Respiratory depression: post-ictal, meningitis, poisoning // Alveolar or chest wall failure: pulmonary contusion, flail chest, diaphragmatic hernia (traumatic or congenital) // Fluid loss: gastroenteritis, femoral / pelvic fractures // Fluid maldistribution: meningococcal shock, anaphylaxis // Heart failure: local anaesthetic toxicity, congenital heart disease

APLS: Systematische aanpak Eerste beoordeling Resuscitatie Tweede beoordeling – opsporen van sleutelkenmerken Spoedbehandeling Stabilisatie, transfer naar definitieve zorg A B C D E Stress the structured approach – reinforce: the need to treat in order of the structured approach the role of repeat assessments the value of using this in record keeping and in communications between staff.

Snelle beoordeling Airway en Breathing Circulatie Effort (ademarbeid) Efficiëntie (doeltreffendheid) Effecten Circulatie Hartfrequentie Polsvolume Capillaire refill time Bloeddruk Huidtemperatuur Disability (neurologie) Bewustzijn Houding Pupillen This should take less than 60s (apart from BP). It is used for assessment, order of interventions, communication both written and verbal.

Interactief airway/breathing Kijk naar de video’s Noteer de tekenen/symptomen van respiratoir falen op een post-it Rangschik deze volgens effort (ademarbeid), efficiëntie en effecten op andere organen. Candidates are divided into their course groups Ask them to look at the video(s) and produce a list of the signs and symptoms under the headings of effort, efficacy and effect You may wish to write: Effort Efficacy Effect On a flipchart. And ask the groups to feedback their list and write these up if you wish.

Interactief: noteer tekenen/symptomen Play each video and ask the candidates to list all of the signs and symptoms – you may need to adjust the sound Stop om 9u15

Interactief: noteer tekenen/symptomen No sound on this video – just visual signs Stop om 9u15, bij tijdstekort deze skippen

Potentieel respiratoir falen Effort (ademarbeid) Efficiëntie (doeltreffendheid) van de ademhaling Effecten van respiratoire insufficiëntie From each group invite a candidate to put the post-its on the right E. Effort: rate, Accessory muscle use, Flaring of nostrils, Child's position, Stridor (mostly insp), Wheeze (exp), Grunting (end-exp, may arise from alveolar/resp bronchiolar pathology, either primary, or secondary to peritonism or raised intracranial pathology) Ask if there are exceptions (neuromuscular, exhaustion, central depression) Efficacy: chest expansion/symmetry, Listen, sat/ colour, Normal SaO2 in oxygen does not rule out resp failure, with an elevated CO2. Ask for imminent sign: silent chest Effects on other systems: difficult to obtain from video. (Heart rate: tachycardia – bradycardia/ skin colour: Pallor, mottling secondary to endogenous epinephrine, cyanosis. Mental status: agitation, restlessness, reduced conscious level, comaPre terminal sign: sat <85% in air

Interactief: circulatie Carlos is 3jaar. Hij heeft sedert enkele uren koorts en is slaperig. Moeder is ongerust, ze vindt hem “anders dan normaal” en komt met hem naar de spoedopname. Candidates are divided in small groups (4-6 people), They have post its and paper Present this case and the following slide and invite candidates to discuss in their groups the initial resuscitation and then think about the differential diagnosis of circulatory failure and the specific interventions that should be given. Invite candidates to provide answers to next two slides, including any other key features that they can think of before moving on to Deepak’s case, e.g.: bilious vomiting, abdominal pain and distension – surgical abdomen pallor and splenomegaly – severe anaemia

Carlos’ case: Eerste beoordeling en opvang Klinisch Opvang A Open Roep om hulp Houd de luchtweg open (eventueel later intubatie) Zuurstof IV toegang en vochtbolus (zo nodig 2-3 x herhalen) Neem bloed af, AB Herbeoordeel B AH 40/min SpO2 niet te meten Geen belangrijke intrekkingen C Bleek HR 170/min Zwakke perifere pulsaties BP 65mmHg systolisch CRT 4 sec D AVPU Allow 2 minutes

Potentieel circulatoir falen Cardiovasculaire tekenen Effecten van circulatoir falen Ask randomly which are: Cardiovascular signs (heart rate, pulse volume, CRT (should not be used as the sole measure of shock and is best obtained on the sternum), blood pressure) Effects on other organs (resp rate, skin temperature and colour, mental status)

Circulatie: andere vormen van shock? Sleutelkenmerken Diagnose Behandeling Braken/ Diarree Gastroenteritis IV/IO Vocht Koorts en rash sepsis IV/IO vocht Antibiotica Allergeen, urticaria Anafylaxie Adrenaline Tekenen van hartfalen Cong.hartafwijking Cardiomyopathie Prostaglandine Diuretica, inotropie Ritmestoornissen Arythmie Anti-aritmie protocollen Hoge glycemie Diabetes Vocht (opgelet!) Insuline Show key features and ask for diagnosis and emergency treatment. Ask whether there are any other key features / diagnoses not listed here. E.g. bilious vomiting, abdominal pain and distension – surgical abdomen pallor and splenomegaly – severe anaemia Allow 4 minutes

Interactief: disability (neurologie) Deepak is 13 jaar, hij werd binnengebracht door de ambulance nadat omstaanders hem bewusteloos aantroffen in het gemeentepark. Zijn vrienden zeggen dat er niets bijzonders gebeurd is, maar er hangt een sterke alcoholgeur in de wachtkamer. Present this case and the following slide and invite candidates to discuss in their groups the initial resuscitation and then think about the differential diagnosis of reduced conscious level and the specific interventions that should be given. Invite candidates to provide answers to next two slides, including any other key features that they can think of before summing up. E.g. headaches, acute onset – cerebrovascular event headaches, high BP – hypertensive encephalopathy vague and inconsistent history, other trauma in an infant – child abuse

Deepak’s case: Eerste beoordeling en opvang Klinisch Opvang A Snurkt Roep om hulp Open luchtweg (mayo?) Zuurstof via NRM IV/IO toegang en vocht Neem bloed af Opwarmen Herbeoordeel B AH 12/min Geen intrekkingen SpO2 niet te meten C HR 100/min Bleek Koude extremiteiten BP 100mmHg systolisch D AVPU Pupillen: traag, gelijk en reactief E Hypothermie - 32oC Allow 2 minutes

Potentieel centraal neurologisch falen Bewustzijn Houding Pupillen For a full AVPU assessment, a response to pain must be undertaken (unless there is a response to voice). Discuss assessing pain – methods of producing a painful stimulus, and what response might be seen: motor, verbal, eyes. This can be used to introduce the fuller assessment with GCS or CCS. Posture Certain postures will not be obvious and may only show themselves when a painful stimulus is given. Discuss difference decorticate/decerebrate Pupils: Mention unilateral fixed dilated pupil and pin-point pupils as useful examples but that details of pupillary abnormalities will be described in the decreased conscious level interactive session.

Disability: andere vormen van coma? Sleutelkenmerk Diagnose Behandeling Bekend met epilepsie Postictaal Ondersteunend (mayo?) monitoring Recent trauma Hoofdletsel Trauma algoritme Bekende onderliggende ziekte Diabetes Metabole ziekte DKA algoritme Metabool protocol Acuut begin en koorts Meningitis Encefalitis Antibiotica Mogelijk intoxicatie Drugs Alcohol Ondersteunend Evt. antidoot Show key features and ask for diagnosis and emergency treatment. Ask whether there are any other key features / diagnoses not listed here. E.g. headaches, acute onset – cerebrovascular event headaches, high BP – hypertensive encephalopathy vague and inconsistent history, other trauma in an infant – child abuse The use of the structured approach in these cases will help ensure early and appropriate treatment. Candidates may practice this in the illness simulations which follow. Allow 4 minutes

Advanced Paediatric Life Support Herkenning en opvang van ernstig zieke kinderen

Snelle beoordeling Airway en Breathing Circulatie Effort (ademarbeid) Efficiëntie (doeltreffendheid) Effecten Circulatie Hartfrequentie Polsvolume Capillaire refill time Bloeddruk Huidtemperatuur Disability (neurologie) Bewustzijn Houding Pupillen This should take less than 60s (apart from BP). It is used for assessment, order of interventions, communication both written and verbal.