IAP ALS Handbook

Erratum:

Location error Suggested correction

Page no 10 brainstem dysfunction Brainstem Dysfunction
Neurological
Impairment
Page No 13 pneumonic mnemonic
Line No 4
Page no. 16 latter later
3rd line
Slow Breathing

Page no 18 naemia anaemia

Caveats of pulse
oximetry
In all other places in the chapter,
Page 28 Altitude is mentioned in feet altitude is mentioned in metres.
Clinical Vignette Suggestion is to change the feet to
metres in clinical vignette
Page 39 Numbering of Table 4.2.3 is wrong Read Table 4.2.3 as Table 4.2.2

Page no 42 Suspect in any infant It should be suspected in any child

Line 8-9
Page no 42 and close monitoring for disease monitor closely for disease
Line 11-12(Airway) progression is required progression.
Page no 42 Humidified High Flow Nasal cannula Humidified High Flow Nasal cannula
Line 19 (HFNC (HHFNC)
Page no 43 evaluated in hospitalized children evaluated in hospitalized children.
Line 13 however randomized studies However randomized studies
(Specific management
of Acute bronchiolitis)

Page no 43 Only if there is severe obstruction the The child is separated from caretaker
Line 19-20 child is separated from caretaker for only in case of severe obstruction.
appropriate management
Page no 44 Terbutaline infusion 0.1-10 mcg/kg/hr Terbutaline infusion 0.1-10
microgram/kg/min
Page no 47 Infants and young children more prone Infants and young children are more
Essence(5th line) to hypoxemia due to high metabolic prone to hypoxemia due to high
demand metabolic demand
Page no 48 Breathing: RR 62/min Breathing:RR-62/min
low SpO2 85% room air Low SpO2 85% on room air

Page no 48 Breathing- Heated humidified Breathing- Humidified supplemental

supplemental oxygen(100%) using a non oxygen (100%) using a non-
breathing mask rebreathing mask
Page no 49 Community acquired pneumonia is Community acquired pneumonia is
Line no 9-10 caused by viruses and bacteria caused by viruses, bacteria
Page no 49 causing a low compliance disease and causing low compliance and
(Cardiogenic hypoxemia hypoxemia
pulmonary edema)

Page no 49 Inflammatory cascade and cytokine Inflammatory cascade and cytokines

(ARDS)
Page no 50 Children with central nervous system Children with central nervous system
(The Outliers) disease or neuromuscular paralysis are disease or neuromuscular paralysis are
unable to mount respiratory distress unable to mount respiratory distress
once they develop significant lung when they develop significant lung
parenchymal disease parenchymal disease
Page no 52 Maintain neck and head to keep Maintain neck and head in slight
Last line extension to keep the airway open.
Page no 53 Adhesive Adhesive tape
Check list for ET
intubation
Page no 53 Special equipment on standby for Special equipment on standby for
Last line difficult airway management- e.g; difficult airway management- e.g.
Cricothyrotomy Cricothyrotomy & Laryngeal Mask
Airway
Page no 54 ETCO2 eTCO2
Essence
Page no 55 LMA’s LMAs
2nd line
Page no 58 Appropriate flow rate-6-10 L/min Appropriate flow rate-4-6 L/min
Simple Oxygen Mask
Page no 62 Creates an oxygen reservoir in Creates an oxygen reservoir in
Principles of HFNC anatomical airways allowing for delivery anatomical airways allowing
of ~ 100% FiO2 for delivery of high concentration of
FiO2

Page no 62 The gas temperature is set around 37 The gas temperature is set around 34
Last line deg C deg C
Page no 63 During weaning support, flow is typically Initially FiO2 is reduced gradually to ~
Second last line reduced by 10-25% over time. 40%. Then flow is typically reduced by
(Weaning from HFNC) 10-25% over time.
Page no 66 The spacer helps suspends...... The spacer helps suspend......
(What does spacer
do?)
Page no 67 Rigid wide bore suction cannula (Tonsil Rigid wide bore suction cannula(Tonsil
(Devices) tip) is preferred for vomit, blood and tip) is preferred for vomit, blood, food
thick secretions particles and other thick secretions
Page no 68 High flow Oxygen (Through NRM/Venturi High flow Oxygen through
Management or High Flow Nasal Cannula(HHHFNC) NRM/Venturi Mask or Heated
Interventions Level 2 Humidified High Flow Nasal
(Airway) Cannula(HHHFNC)
Page no 68 HHFNC/Non-invasive ventilation HHHFNC/ Non-invasive ventilation
Management
Interventions Level 2
(Lung Parenchymal
disease)

Page no 68 HHFNC/NIV HHHFNC/NIV

Management
Interventions Level 2
(Disordered control of
breathing )
Page no 68 Urine Output every 4th hourly Urine output 4 hourly
Management
Interventions Level 2
(Monitoring of
cardiorespiratory
status)

Page no 69 Heart rate is written before RR and Spo2 Respiratory rate 30/min, SpO2 92% in
Clinical vignette room air, heart rate 160/min, weak
peripheral & central pulses, CRT> 3
seconds and BP of 78/54 mmHg. (More
in ABCDE order)
Page no 70 Flash CRP Flash CRT
6th line
Page no 70 Remember this is not normal BP for that Needs more elaboration
ESSENCE(Blood age. It is only the lower acceptable cut
Pressure) off
Page no 71 Nephrotic syndrome as a cause of
Hypovolemic shock shock?)
Page no 72 Unilateral Hyper –resonance,diminished Unilateral Hyper –
Tension breath sounds and tracheal resonance,diminished breath sounds
pneumothorax deviation............................. clinches the and tracheal
diagnosis. deviation............................. clinches
the diagnosis. In infants, the tracheal
deviation may not be present.

Page no 74 isotonic crystalloid isotonic crystalloids

Compensated
hypovolemic or
distributive shock
Page no 75 To be added: correct hypoglycaemia,
Cardiogenic shock hypothermia
Page no 75 Anaphylactic shock IM epinephrine 0.1 Anaphylactic shock IM epinephrine
Distributive shock mg/kg 0.01 mg/kg
epinephrine infusion 0.1 to mcg/kg/hr epinephrine infusion 0.1 to 1
mcg/kg/min
Page no 79 His heart rate is 170/min, RR is 42/min, His RR is 42/min, air entry equal on
Clinical vignette both sides, mild intercostal recessions,
SpO2 84% in room air, HR 170/min,
central pulses palpable, peripheral
pulse feeble, BP 74/52 mmHg & temp
36 C (ABCDE Sequence)
Page no 82 Hyper resonance on percussion Hyper resonant note on percussion
Tension
pneumothorax

Page no 82 Wide bore IV cannula ( 20-24 gauge in Wide bore IV cannula ( 22-24 gauge in
Circulation infants) infants)
Page no 85 Centre’s dealing Centers dealing
Multidisciplinary team
and referral

Page no 86 Fracture of long bones in children <than Fracture of long bones in children <3
The Outliers 3 years of age years of age
(Examination)
Page no 86 Supporting the ABC are crucial Supporting ABC are crucial
Take home message
Page no 88 Trauma is a leading cause of death in Trauma is a leading cause of death in
Core concept children exsanguinations and children, exsanguinations (severe loss
hemorrhagic shock of blood ) and hemorrhagic shock
Page no 90 Given by pull push mathod Given by pull push method
Hypotensive shock
Page no 90 Minimizing crystalloid-basedresuscitation Minimizing crystalloid based
(AcoTS 4th Line) immediate administration of predefined resuscitation, immediate
blood product administration of predefined blood
products
Page no 90 Fresh whole blood is warm , volume In Warm fresh whole blood ,volume
(Whole blood) close to 500ml close to 500 ml
Page no 90 Once a 200 ml unit of FFP IS thawed Once a 200 ml of FFP IS thawed
(Plasma)
Page no 90 Single donor platelets are equal in Platelet concentration in one single
(Platelets) volume and platelet concentration to 4-6 donor unit is equal to 4-6 units of
units of random donor platelets random donor platelets
Page no 92 Tachypnoea Tachypnea
(Breathing)
Page no93 Platelets –RDP unit per 5 Kg Platelets –RDP 1 unit per 5 Kg
Page no 98 and bita adrenergic And beta adrenergic
(Amiodarone)
Page no 108 How long should CPR be delivered CPR if How long should CPR be delivered if
(Question to be ROSC is not achieved ROSC is not achieved
answered)
Page no 114 endotrachea Endotracheal
(circulation)
Page no 118 No single factorcan No single factor can
(Can we predict
Neurological
Outcome)
Page no 119 Endotracheal Endotracheal
Quick recall epinephrine 1:10000 strength 0.1ml/kg epinephrine 1:1000 strength 0.1ml/kg
(Medication)
Page no 120 Provision of high quality CPRis Provision of high quality CPR is
(Take home message)
Page no 122 midline,2-3 cm above the external Distal femur:midline,2-3 cm above the
(Distal femur) condyle lateral condyle
Page no 123 It should be not be kept for more than It should not be kept for more than 24
24 hours hours
Page no 125 Who developsigns of pulmonary edema Who develop signs of pulmonary
(Monitoring fluid edema
therapy)

Page no 125 and ionotroper esponsive shock and ionotrop responsive shock
(Monitoring fluid
therapy) second last
line
Page no 127 Ionized hypocalcemia should be Ionized hypocalcemia should be
Hypocalcemia evaluated for in the first hour evaluated in the first hour
Page no 137 Choose energy dose based on rhythm Choose energy dose based on weight
Steps in Defibrillation
Page no 6138 High flow Oxygen (Through NRM/Venturi High flow Oxygen through
Management or High Flow Nasal Cannula(HHHFNC) NRM/Venturi Mask or Heated
Interventions Level 2 Humidified High Flow Nasal
(Airway) Cannula(HHHFNC)
Page no 138 Level 1:Access (with 90 sec) Level 1:Access (within 90 sec)
 Circulation Level 2:Access (with 90 sec) Level 2:Access (within 90 sec)

Page no 151 For score 2 :Moans to pain Moans to pain

Modified Glasgow
Coma Scale(Infant) For score 1 :one none

Page 152/154/165 the unconscious child, there is some

discrepancy in the blood glucose level
that has to be maintained. On page 152,
under disability, it's written to maintain BG
between 80 to 120mg/dl, and same levels
are mentioned on page 154, under
management of raised ict. But in the table
on page 156, point 4, under Metabolic
disturbances, management intervention
level 3, optimal glycemic control is 150 to
180mg%. Which of the two is to be
followed?

Page no 161 Palpable pulse------------Deceased Palpable pulse----- NO---- Deceased

Pediatric trauma
triage system Palpable pulse----------- Provide Rescue Palpable pulse----- Yes---- Provide
Breaths Rescue Breaths

 Dear all,

Greetings from Delhi.

CIAP has entrusted the IAP ALS BLS group to carry out following two programs in association
with the IAP branches, and we all will be participating in these,on voluntary basis.

Therefore, this is prudent to know about them:-

1. MEMS (Management of medical emergencies in the schools).

The first national TOT will be held at the CIAP office on 05.02.19 (before lunch) to the
invited delegates, who in turn will conduct further programs in various zones.
2. IAP ALS MAP (Mass Awareness Program).
The first national TOT will be held at the CIAP office on 05.02.19 (after the lunch) to the
invited delegates, who in turn will conduct further programs in various zones.
Website live demonstration will be done in continuation with the ALS MAP and before the
GBM.

Kindly note that these two programs are sponsored by the CIAP, hence the invitation was
sent by the CIAP. If you are interested in the pre-lunch or post lunch sessions, you are
invited to attend.
This is heartening that our website has been used smoothly and initial teething problems
are mostly over. If somebody is interested in the live demo of the website, can attend this
session also.
If you need any assistance related to the venue or seeking directions, please contact these
persons from the CIAP :-
 Sanket : 918080934902
 Dsouza: 91 9869379382
Other issues:
The ALS equipment was replenished about two years ago and may be in good shape. If
there is some pressing requirement, this should be met
 The outgoing ZC In consultation with the JZC are requested to make a list of existing
equipment and the urgently needed one.
Any suggestions as how to improvethe ALS provider courses are most welcome.
With regards –
Dr.A.K.Sharma

P.S.: There may be a curiosity about the IAP ALS MAP.

IAP ALS MAP :
The number of the ALS provider courses has not picked as expected, despite availability of
our own manual and module. Even many instructors are not getting chances to participate
in two mandatory courses per year to retain their faculty status.
The participation of pediatricians in ALS provider courses has now been limited to the
residents. The reasons cited for others have been - difficult to spare two days, risk of
failure and confusing the ALS courses as critical care courses - hence not required for non
PICU setting.
We have complimentary ALS courses for nurses, where they can learn without evaluation
and also have BLS MAP for laypersons (free of charge) but no such provision for ALS
The CIAP has given a helping hand for promoting the one day IAP ALS Mass Awareness
Programs  in all the zones, in association with the local IAP branches. The first TOT will be
held at the CIAP office in Mumbai - post lunch on 05.02.2019.

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A.K. Sharma
akgeeta_sharma@yahoo.co.in
+91 93122 51513