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I General Background II Items not fit to local practice III Items not well-defined or questionable IV Hot Issues V Future – PALS The topics selected for discussion are based on 3 years of feedback from participants in PALS Provider Courses in Japan. Localization issues, by definition, are different for each country. We hope to encourage a free exchange of information to identify issues of importance to each country and region. I General Background 1. Health Care System EMS/EMT System Who is responsible for PALS in your country? Is PALS mandatory for pediatricians, physicians, nurses, or EMTs? Phone 911 (Provider p. 1) Portable Phone US statistics Pretest Most participants are shy and passive (Instructor p. 21) Aggressive attitude among BLS/ACLS providers PALS targets general pediatricians Not aimed at ER/Adult/Anesthesia/ICU Physicians 3. How to deliver bad news in different cultures Brain Death (Provider p. 419) Coping with Death (Provider p. 397) The Child as a Patient (Provider p.410) Family Presence of family during resuscitation efforts Appropriate amount and type of information to give regarding Interpretation of physician’s behavior (sitting or standing, II. Items not fit to local practice 1. Lidocaine (Provider p. 210) and Amiodarone (Provider p. 205) 2. Adenosine (Provider p. 203) and ATP Pediatric pads The role of AED training (Provider p. 192) Initial CPR can be neglected Do children below 8 really need an ‘AED First’ approach? Defibrillation, intubation, LMA, IV medications Role of paramedics, nurses 6. Attitude of nurses and no RTs 7. Sedation 5000+ MRIs, 10,000 hospitals (Japan) No designated persons for monitoring during MRI or sedation III Items not well defined or questionable 1. PALS 8 years, 25 kg and over What about 10 years, 35 kg? 15 years, 40 kg? 1/2 depth of chest too much? (Provider p .61) 3. Defibrillation when desired setting is not available 5. Laryngoscope blade in esophagus (Provider p. 102-104) Risk of laryngeal trauma during withdrawal from esophagus is overly stressful and not in accordance with local pediatric practice Should recommend pillow below the head rather than the shoulder Activate EMS if unresponsive after one minute (p. 67) What to do until EMS arrives? Minus 100 mmHg suction setting at wall too low (Provider p. 293) Pressure and flow at catheter tip should be stressed Confirm suction tube insertion length each time 0, 00 tube size notation not recommended Tube fixation: remove pillows (neck flexion) should be stressed Stress danger of tube replacement within 48 h of tracheostomy Use of replacement catheter/guide be stressed Use of fenestrated tube for speech – not a PALS topic 9. Precautions for PICC, CV catheter and stopcock use Watch for pushing, pressure, and dislodgement (Provider p. 296) Use of pulse oximeter simulator in training Beyond pulse rate detection (Provider p. 110 ) Pulse oximeter in only one case scenario (Provider p. 117) Pulse oximeter, but no ECG more frequent Issues related to oximeters (motion, perfusion) Immediate action to alarm signals, crying wolf syndrome Recurrent apnea, frequency of desaturation, imminent resp arrest? 11. Potentially Reversible Causes of Arrest (Provider p. 189) Currently 4H and 4T (Hypoxemia, Hypovolemia, Hypothermia, Hyper/Hypokalemia and Tamponade, Tension pneumothorax, Toxins, Thromboembolism) Add Hypoglycemia and hurT for 5H and 5T? Jackson Rees vs BVM (Provider p. 53) Mouth to Mask – risk of infection (Provider p. 53) Transcutaneous pacemaker? Cricothyroidotomy 13. Do we need a flat line protocol? (Provider p. 187) 14. Response to breakage of IO needle (Provider p. 158) 15. Should we recommend using a left radial artery line? (Provider p. 167) 16. Capnometer/colorimetric devices Effectiveness and availability Leak around ETT, low cardiac output (Provider p. 105) Norepinephrine vs Epinephrine or other medications? 18. Broselow pediatric resuscitation tape (Provider p. 22) - localization 19. Video presentations – translation and localization 20. Importance of PBLS IV Hot Issues 1. Compression ventilation ratios in children (Provider p. 63) 2. Role of rescue breaths in children (Provider p. 50) 3. Hypothermia in children When, how low, and how long Outcome studies 4. Hyperventilation in children 5. High-dose Epinephrine in children 6. Vasopressin and Epinephrine (Provider p. 210) Acute myocarditis Epinephrine for Asthma/anaphylaxis Cricothyrotomy Pulse Oximeter (interpretation issues) CO hemoglobin, Met-hemoglobin Cautions with patients on supplemental oxygen Fatigue and effectiveness during CPR Use of patient simulators Outcome studies (PALS) CPR Registry Japan as one hospital (lack of research/support staff) 4. Assessment of local needs (within the healthcare professional field) Balancing PALS and BLS E-learning and course length Should we concentrate more on PBLS in Asia? “push hard and push fast on the center of the chest without interruption, defibrillate promptly, and don’t provider too many rescue breaths per minute” – too complicated? CPR isn’t performed as well as it should be (Jan 18, 2005 US News Ambulance crews did chest compressions for only about half the time they could have been doing them – patients went for long periods without blood flow. Other activities (defibrillator use, checking for pulse) only accounted for 15-20% of the missing time. Chest compressions too shallow 37% of the time (in-hospital

Source: http://www.jspicc.jp/news/pdf/news001_agenda.pdf