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Pediatric Resuscitation
Pediatric Cardiac Arrest
Usually secondary to respiratory failure or arrest
Most Important Intervention
Adequate oxygenation, ventilation
Basic Life Support
Airway• Head-tilt/chin-lift method• Big tongue; Forward jaw displacement critical• Avoid extreme hyperextension• With possible neck injury, jaw thrust
Basic Life Support
Breathing• Look-Listen-Feel• Limit to volume causing chest rise• Children usually underventilated!• Use BVM only if proficient• Pedi BVM’s should not have pop-off valves
Basic Life Support
Breathing• Do NOT use demand valve on children• Ventilate infants, children every 3 seconds
Basic Life Support
Circulation• Infants: brachial• Children: carotid
Basic Life Support
Circulation• Infant chest compressions – 2 fingers– 1 finger width below nipple line– 1/2 - 1 inches–At least 100/minute
Basic Life Support
Circulation• Child chest compressions–One hand– Lower half of sternum – 1 - 1.5 inches– 100/minute
Basic Life Support
Circulation• Child CPR–Maintain continuous head tilt with hand on
forehead–Perform chin lift with other hand while
ventilating
Best Sign of Effective Ventilation
Chest Rise
Best Sign of Effective Circulation
Pulse with Each Compression
Oxygen Therapy
Initiate ASAP Do not delay BLS to obtain oxygen
Oxygen Therapy
Use highest possible FiO2
• No risk in short term100% O2
Humidify if possible• Avoids plugging airways, adjuncts
Endotracheal Intubation
Need to intubate is not same as need to ventilate!
Endotracheal Intubation
Proper tube size• Same size as child’s little finger• Child > 1 year: [(Age + 16 ) / 4]
Endotracheal Intubation
Children < 8 years old• Small tracheal diameter• Narrow cricoid ring• Uncuffed tubes
Infants, small children• Narrow, soft epiglottis• Straight blade
Endotracheal Intubation
Attempts not >30 seconds Bradycardia: oxygenate, ventilate
Endotracheal Intubation
Avoid hyperextension Use “sniffing position” Lift up; do not pry back
Endotracheal Intubation
Confirm placement by:• Seeing tube go through cords• Chest rise• Equal breath sounds• No sounds over epigastrium
• CO2 in exhaled air
Endotracheal Intubation
Mark tube at corner of mouth Avoid excessive head movement Frequently reassess breath sounds Ventilate to cause gentle chest rise
Endotracheal Drugs
Epinephrine, atropine, lidocaine
Endotracheal Intubation
Drug administration• Do not delay while attempting IV access• Dilute with normal saline• Stop compressions• Inject through catheter passed beyond ETT• Follow 10 rapid ventilations
Cricothyrotomy
Surgical contraindicated in children <12 Narrowing of trachea at cricoid ring makes
procedure hazardous Use needle technique only
Vascular Access
Same reasons as adults• Drugs• Fluids
Scalp Veins
No value in cardiac arrest Useful in infants < 1 year old for
maintenance fluids, drug route
Scalp Veins
Rubber band for tourniquet 21, 23 gauge butterfly Attach syringe, flush needle before
inserting
Scalp Veins
Point needle in direction of blood flow Leave syringe attached, inject 1cc saline
after entering vein to check infiltration
Hand, Arm, Foot Veins
22 gauge catheter for smaller children Restrain extremity before attempting Incise overlying skin with 19 gauge needle Flush needle as with scalp vein technique
External Jugular Life-threatening situations only 22 gauge catheter Restrain by wrapping in sheet Extend head over end of table, rotate 900
If vein perforates, do not go to other side• Risk of paratracheal hematoma, airway
obstruction
Prevention of Fluid Overload
Avoid using bags over 250cc Use mini-drip sets, Volutrols Fluid resuscitation: 20cc/kg boluses
Intraosseous Cannulation
Placement of cannula into long bone intramedullary canal (marrow space)
Intraosseous Cannulation
Indication• Vascular access required• Peripheral site cannot be obtained– In two attempts, or–After 90 seconds
Intraosseous Cannulation
Devices• 16 gauge hypodermic needle • Spinal needle with stylet• Bone marrow needle (preferred)
Intraosseous Cannulation
Site• Anterior tibia• 1 - 3 cm below knee • Medial to tibial tuberosity
Intraosseous Cannulation
Contraindications• Fractures• Osteogenesis imperfecta• Osteoporosis• Failed attempt on same bone
Intraosseous Cannulation
Needle in place if:• Lack of resistance felt• Needle stands without support• Bone marrow aspirated• Infusion flows freely
What can be put thru an IO?
Anything that can be put through an IV!
Remember…….
You don’t need a line to give drugs during a code.
Epinephrine, atropine, lidocaine can go down tube
Defibrillation
90% of pediatric cardiac arrest is• Asystole, or • Bradycardic PEA
Defibrillation seldom needed
Defibrillation
Pediatric VF suggests• Electrolyte imbalances• Drug toxicity• Electrical injury
Defibrillation
Paddle diameter:• Infants: 4.5 cm• Children: 8.0 cm
Largest paddles that contact entire chest wall without touching
If pediatric paddles unavailable, use adult paddles with A-P placement
Defibrillation
Energy Settings• Initial: 2 J/kg• Repeat: 4 J/kg
Cardioversion
Cardiovert only if signs of decreased perfusion
Energy settings:• Initial: 0.5 - 1.0 J/kg• Repeat: 2.0 J/kg
Cardioversion
Narrow-complex tachycardia, rate < 200• Usually sinus tachycardia• Look for treatable underlying cause• Do not cardiovert
Cardioversion
Narrow-complex tachycardia, rate > 230• Usually supraventricular tachycardia• Frequently associated with congenital
conduction abnormalities
Cardioversion
Narrow-complex tachycardia, rate > 230• If hemodynamically stable, transport• Adenosine may be considered
Cardioversion
Narrow-complex tachycardia, rate > 230• If hemodynamically unstable, cardiovert• If no conversion after two shocks, consider
possibility rhythm is sinus tachycardia
Drug Therapy
Epinephrine• Asystole, bradycardia PEA• Stimulates electrical/mechanical activity
Drug Therapy
Epinephrine Dosage• IV or IO: 0.01 mg/kg 1:10,000• ET: 0.1 mg/kg 1:1000
Drug Therapy
Atropine• 0.02 mg/kg IV or IO–Double ET dose
• Minimum dose: 0.1 mg to avoid paradoxical bradycardia
• Maximum single dose: –Child: 0.5 mg–Adolescent: 1mg
Drug Therapy
Most bradycardias respond to• Oxygen• Ventilation
For bradycardia 2o to hypoxia/ischemia, preferred first drug is epinephrine