What are the APLS (Advanced Pediatric Life Support) criteria for assessing and managing a child's condition in emergency care?

Advanced Pediatric Life Support (APLS) Criteria for Pediatric Emergency Assessment and Management

The APLS criteria provide a structured approach to assessing and managing pediatric emergencies, focusing on early recognition, stabilization, and timely transfer to appropriate facilities to reduce morbidity and mortality in critically ill children. 1

Structured Assessment Approach

Initial Assessment (ABCD)

• APLS follows the ABCD approach of life support courses, focusing on rapid identification and management of life-threatening conditions 1
• Assessment begins with airway patency, followed by breathing, circulation, and disability evaluation 1
• For children with suspected cervical spine injury, use jaw thrust to open the airway; if unsuccessful, proceed to head tilt-chin lift as establishing a patent airway takes priority 1
• In infants and young children, optimal positioning may require recessing the occiput or elevating the torso to avoid undesirable cervical flexion 1

Triage Assessment

• APLS criteria include emergency triage assessment to rapidly identify children requiring immediate intervention 1
• Vital signs should be compared to age-specific normal ranges to identify deviations requiring intervention 1
• Continuous monitoring of heart rate, respiratory rate, oxygen saturation, and blood pressure is essential for critically ill children 1

Management Principles

Respiratory Support

• For children with respiratory distress, provide supplemental oxygen when oxygen saturation falls below normal range 1
• Avoid routine hyperventilation, even in head injury cases (Class III, LOE C) 1
• Brief intentional hyperventilation may be used temporarily if signs of impending brain herniation are present 1
• For children with tracheostomies, providers should know how to assess patency, clear the airway, replace the tube, and perform CPR using the artificial airway 1

Circulatory Support

• Administer at least 30 mL/kg of IV crystalloid fluid within the first 3 hours for children with septic shock 2
• For pediatric patients unresponsive to fluid resuscitation, begin peripheral inotropic support until central venous access can be attained 2
• Consider adding vasodilator therapies for children with low cardiac output and elevated systemic vascular resistance with normal blood pressure 2
• Norepinephrine is recommended as the first-choice vasopressor if the patient remains hypotensive despite adequate fluid resuscitation 2

Medication Administration

• The recommended intravenous epinephrine dose for pediatric resuscitation is 0.01 to 0.03 mg/kg 3
• Higher doses of epinephrine are not recommended for routine use 3
• Intravenous administration is the preferred route for emergency medications 3
• While vascular access is being established, medications may be administered via the endotracheal route if necessary 3

Special Considerations

Sedation and Pain Management

• During deep sedation, there must be one person whose only responsibility is to constantly observe the patient's vital signs, airway patency, and adequacy of ventilation 1
• This individual must, at minimum, be trained in PALS and capable of assisting with any emergency event 1
• At least one individual must be present who is trained in advanced pediatric life support and skilled in rescuing a child with airway complications 1
• Required skills include airway opening, secretion suctioning, providing CPAP, inserting supraglottic devices, performing bag-valve-mask ventilation, tracheal intubation, and cardiopulmonary resuscitation 1

Children with Special Healthcare Needs

• Children with special healthcare needs may require emergency care for chronic conditions, failure of support technology, progression of underlying disease, or unrelated events 1
• Parents, school nurses, and home healthcare providers should be trained in emergency assessment and management for children with special needs 1
• For children with tracheostomies, providers should be able to ventilate via the tracheostomy tube and verify effectiveness by assessing chest expansion 1

Common Pitfalls and Caveats

• Delays in initiating positive pressure ventilation and chest compressions are common errors in pediatric resuscitation 4
• Many providers incorrectly perform continuous chest compressions before establishing an advanced airway, rather than following the recommended ratio 4
• Medication errors are frequent in pediatric emergencies, with both underdosing and overdosing occurring commonly 4
• Avoid fluid overresuscitation as it can delay organ recovery, prolong ICU stay, and increase mortality 2
• The standard approach may need modification based on individual patient characteristics, particularly cardiac function 2

Equipment Requirements

• Age and size-appropriate equipment must be readily available for pediatric emergencies 1
• Essential equipment includes functioning suction apparatus, oxygen delivery devices, bag-valve masks, and positive-pressure ventilation capabilities 1
• For deep sedation or advanced life support, ECG monitoring and a pediatric defibrillator should be readily available 1
• Vascular access equipment appropriate for pediatric patients of various ages should be accessible 1