Pediatric Resuscitation

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Pediatric Resuscitation

  1. 1. Pediatric Resuscitation
  2. 2. Pediatric Cardiac Arrest Usually secondary to respiratory failure or arrest
  3. 3. Most Important Intervention <ul><li>Adequate oxygenation, ventilation </li></ul>
  4. 4. Basic Life Support <ul><li>Airway </li></ul><ul><ul><li>Head-tilt/chin-lift method </li></ul></ul><ul><ul><li>Big tongue; Forward jaw displacement critical </li></ul></ul><ul><ul><li>Avoid extreme hyperextension </li></ul></ul><ul><ul><li>With possible neck injury, jaw thrust </li></ul></ul>
  5. 5. Basic Life Support <ul><li>Breathing </li></ul><ul><ul><li>Look-Listen-Feel </li></ul></ul><ul><ul><li>Limit to volume causing chest rise </li></ul></ul><ul><ul><li>Children usually underventilated ! </li></ul></ul><ul><ul><li>Use BVM only if proficient </li></ul></ul><ul><ul><li>Pedi BVM’s should not have pop-off valves </li></ul></ul>
  6. 6. Basic Life Support <ul><li>Breathing </li></ul><ul><ul><li>Do NOT use demand valve on children </li></ul></ul><ul><ul><li>Ventilate infants, children every 3 seconds </li></ul></ul>
  7. 7. Basic Life Support <ul><li>Circulation </li></ul><ul><ul><li>Infants: brachial </li></ul></ul><ul><ul><li>Children: carotid </li></ul></ul>
  8. 8. Basic Life Support <ul><li>Circulation </li></ul><ul><ul><li>Infant chest compressions </li></ul></ul><ul><ul><ul><li>2 fingers </li></ul></ul></ul><ul><ul><ul><li>1 finger width below nipple line </li></ul></ul></ul><ul><ul><ul><li>1/2 - 1 inches </li></ul></ul></ul><ul><ul><ul><li>At least 100/minute </li></ul></ul></ul>
  9. 9. Basic Life Support <ul><li>Circulation </li></ul><ul><ul><li>Child chest compressions </li></ul></ul><ul><ul><ul><li>One hand </li></ul></ul></ul><ul><ul><ul><li>Lower half of sternum </li></ul></ul></ul><ul><ul><ul><li>1 - 1.5 inches </li></ul></ul></ul><ul><ul><ul><li>100/minute </li></ul></ul></ul>
  10. 10. Basic Life Support <ul><li>Circulation </li></ul><ul><ul><li>Child CPR </li></ul></ul><ul><ul><ul><li>Maintain continuous head tilt with hand on forehead </li></ul></ul></ul><ul><ul><ul><li>Perform chin lift with other hand while ventilating </li></ul></ul></ul>
  11. 11. Best Sign of Effective Ventilation Chest Rise
  12. 12. Best Sign of Effective Circulation Pulse with Each Compression
  13. 13. Oxygen Therapy <ul><li>Initiate ASAP </li></ul><ul><li>Do not delay BLS to obtain oxygen </li></ul>
  14. 14. Oxygen Therapy <ul><li>Use highest possible FiO 2 </li></ul><ul><ul><li>No risk in short term100% O 2 </li></ul></ul><ul><li>Humidify if possible </li></ul><ul><ul><li>Avoids plugging airways, adjuncts </li></ul></ul>
  15. 15. Endotracheal Intubation Need to intubate is not same as need to ventilate!
  16. 16. Endotracheal Intubation <ul><li>Proper tube size </li></ul><ul><ul><li>Same size as child’s little finger </li></ul></ul><ul><ul><li>Child > 1 year: [(Age + 16 ) / 4] </li></ul></ul>
  17. 17. Endotracheal Intubation <ul><li>Children < 8 years old </li></ul><ul><ul><li>Small tracheal diameter </li></ul></ul><ul><ul><li>Narrow cricoid ring </li></ul></ul><ul><ul><li>Uncuffed tubes </li></ul></ul><ul><li>Infants, small children </li></ul><ul><ul><li>Narrow, soft epiglottis </li></ul></ul><ul><ul><li>Straight blade </li></ul></ul>
  18. 18. Endotracheal Intubation <ul><li>Attempts not >30 seconds </li></ul><ul><li>Bradycardia: oxygenate, ventilate </li></ul>
  19. 19. Endotracheal Intubation <ul><li>Avoid hyperextension </li></ul><ul><li>Use “sniffing position” </li></ul><ul><li>Lift up; do not pry back </li></ul>
  20. 20. Endotracheal Intubation <ul><li>Confirm placement by: </li></ul><ul><ul><li>Seeing tube go through cords </li></ul></ul><ul><ul><li>Chest rise </li></ul></ul><ul><ul><li>Equal breath sounds </li></ul></ul><ul><ul><li>No sounds over epigastrium </li></ul></ul><ul><ul><li>CO 2 in exhaled air </li></ul></ul>
  21. 21. Endotracheal Intubation <ul><li>Mark tube at corner of mouth </li></ul><ul><li>Avoid excessive head movement </li></ul><ul><li>Frequently reassess breath sounds </li></ul><ul><li>Ventilate to cause gentle chest rise </li></ul>
  22. 22. Endotracheal Drugs Epinephrine, atropine, lidocaine
  23. 23. Endotracheal Intubation <ul><li>Drug administration </li></ul><ul><ul><li>Do not delay while attempting IV access </li></ul></ul><ul><ul><li>Dilute with normal saline </li></ul></ul><ul><ul><li>Stop compressions </li></ul></ul><ul><ul><li>Inject through catheter passed beyond ETT </li></ul></ul><ul><ul><li>Follow 10 rapid ventilations </li></ul></ul>
  24. 24. Cricothyrotomy <ul><li>Surgical contraindicated in children <12 </li></ul><ul><li>Narrowing of trachea at cricoid ring makes procedure hazardous </li></ul><ul><li>Use needle technique only </li></ul>
  25. 25. Vascular Access <ul><li>Same reasons as adults </li></ul><ul><ul><li>Drugs </li></ul></ul><ul><ul><li>Fluids </li></ul></ul>
  26. 26. Scalp Veins <ul><li>No value in cardiac arrest </li></ul><ul><li>Useful in infants < 1 year old for maintenance fluids, drug route </li></ul>
  27. 27. Scalp Veins <ul><li>Rubber band for tourniquet </li></ul><ul><li>21, 23 gauge butterfly </li></ul><ul><li>Attach syringe, flush needle before inserting </li></ul>
  28. 28. Scalp Veins <ul><li>Point needle in direction of blood flow </li></ul><ul><li>Leave syringe attached, inject 1cc saline after entering vein to check infiltration </li></ul>
  29. 29. Hand, Arm, Foot Veins <ul><li>22 gauge catheter for smaller children </li></ul><ul><li>Restrain extremity before attempting </li></ul><ul><li>Incise overlying skin with 19 gauge needle </li></ul><ul><li>Flush needle as with scalp vein technique </li></ul>
  30. 30. External Jugular <ul><li>Life-threatening situations only </li></ul><ul><li>22 gauge catheter </li></ul><ul><li>Restrain by wrapping in sheet </li></ul><ul><li>Extend head over end of table, rotate 90 0 </li></ul><ul><li>If vein perforates, do not go to other side </li></ul><ul><ul><li>Risk of paratracheal hematoma, airway obstruction </li></ul></ul>
  31. 31. Prevention of Fluid Overload <ul><li>Avoid using bags over 250cc </li></ul><ul><li>Use mini-drip sets, Volutrols </li></ul><ul><li>Fluid resuscitation: 20cc/kg boluses </li></ul>
  32. 32. Intraosseous Cannulation <ul><li>Placement of cannula into long bone intramedullary canal (marrow space) </li></ul>
  33. 33. Intraosseous Cannulation <ul><li>Indication </li></ul><ul><ul><li>Vascular access required </li></ul></ul><ul><ul><li>Peripheral site cannot be obtained </li></ul></ul><ul><ul><ul><li>In two attempts, or </li></ul></ul></ul><ul><ul><ul><li>After 90 seconds </li></ul></ul></ul>
  34. 34. Intraosseous Cannulation <ul><li>Devices </li></ul><ul><ul><li>16 gauge hypodermic needle </li></ul></ul><ul><ul><li>Spinal needle with stylet </li></ul></ul><ul><ul><li>Bone marrow needle (preferred) </li></ul></ul>
  35. 35. Intraosseous Cannulation <ul><li>Site </li></ul><ul><ul><li>Anterior tibia </li></ul></ul><ul><ul><li>1 - 3 cm below knee </li></ul></ul><ul><ul><li>Medial to tibial tuberosity </li></ul></ul>
  36. 36. Intraosseous Cannulation <ul><li>Contraindications </li></ul><ul><ul><li>Fractures </li></ul></ul><ul><ul><li>Osteogenesis imperfecta </li></ul></ul><ul><ul><li>Osteoporosis </li></ul></ul><ul><ul><li>Failed attempt on same bone </li></ul></ul>
  37. 37. Intraosseous Cannulation <ul><li>Needle in place if: </li></ul><ul><ul><li>Lack of resistance felt </li></ul></ul><ul><ul><li>Needle stands without support </li></ul></ul><ul><ul><li>Bone marrow aspirated </li></ul></ul><ul><ul><li>Infusion flows freely </li></ul></ul>
  38. 38. What can be put thru an IO? Anything that can be put through an IV!
  39. 39. Remember……. <ul><li>You don’t need a line to give drugs during a code. </li></ul><ul><li>Epinephrine, atropine, lidocaine can go down tube </li></ul>
  40. 40. Defibrillation <ul><li>90% of pediatric cardiac arrest is </li></ul><ul><ul><li>Asystole, or </li></ul></ul><ul><ul><li>Bradycardic PEA </li></ul></ul><ul><li>Defibrillation seldom needed </li></ul>
  41. 41. Defibrillation <ul><li>Pediatric VF suggests </li></ul><ul><ul><li>Electrolyte imbalances </li></ul></ul><ul><ul><li>Drug toxicity </li></ul></ul><ul><ul><li>Electrical injury </li></ul></ul>
  42. 42. Defibrillation <ul><li>Paddle diameter: </li></ul><ul><ul><li>Infants: 4.5 cm </li></ul></ul><ul><ul><li>Children: 8.0 cm </li></ul></ul><ul><li>Largest paddles that contact entire chest wall without touching </li></ul><ul><li>If pediatric paddles unavailable, use adult paddles with A-P placement </li></ul>
  43. 43. Defibrillation <ul><li>Energy Settings </li></ul><ul><ul><li>Initial: 2 J/kg </li></ul></ul><ul><ul><li>Repeat: 4 J/kg </li></ul></ul>
  44. 44. Cardioversion <ul><li>Cardiovert only if signs of decreased perfusion </li></ul><ul><li>Energy settings: </li></ul><ul><ul><li>Initial: 0.5 - 1.0 J/kg </li></ul></ul><ul><ul><li>Repeat: 2.0 J/kg </li></ul></ul>
  45. 45. Cardioversion <ul><li>Narrow-complex tachycardia, rate < 200 </li></ul><ul><ul><li>Usually sinus tachycardia </li></ul></ul><ul><ul><li>Look for treatable underlying cause </li></ul></ul><ul><ul><li>Do not cardiovert </li></ul></ul>
  46. 46. Cardioversion <ul><li>Narrow-complex tachycardia, rate > 230 </li></ul><ul><ul><li>Usually supraventricular tachycardia </li></ul></ul><ul><ul><li>Frequently associated with congenital conduction abnormalities </li></ul></ul>
  47. 47. Cardioversion <ul><li>Narrow-complex tachycardia, rate > 230 </li></ul><ul><ul><li>If hemodynamically stable, transport </li></ul></ul><ul><ul><li>Adenosine may be considered </li></ul></ul>
  48. 48. Cardioversion <ul><li>Narrow-complex tachycardia, rate > 230 </li></ul><ul><ul><li>If hemodynamically unstable, cardiovert </li></ul></ul><ul><ul><li>If no conversion after two shocks, consider possibility rhythm is sinus tachycardia </li></ul></ul>
  49. 49. Drug Therapy <ul><li>Epinephrine </li></ul><ul><ul><li>Asystole, bradycardia PEA </li></ul></ul><ul><ul><li>Stimulates electrical/mechanical activity </li></ul></ul>
  50. 50. Drug Therapy <ul><li>Epinephrine Dosage </li></ul><ul><ul><li>IV or IO: 0.01 mg/kg 1:10,000 </li></ul></ul><ul><ul><li>ET: 0.1 mg/kg 1:1000 </li></ul></ul>
  51. 51. Drug Therapy <ul><li>Atropine </li></ul><ul><ul><li>0.02 mg/kg IV or IO </li></ul></ul><ul><ul><ul><li>Double ET dose </li></ul></ul></ul><ul><ul><li>Minimum dose: 0.1 mg to avoid paradoxical bradycardia </li></ul></ul><ul><ul><li>Maximum single dose: </li></ul></ul><ul><ul><ul><li>Child: 0.5 mg </li></ul></ul></ul><ul><ul><ul><li>Adolescent: 1mg </li></ul></ul></ul>
  52. 52. Drug Therapy <ul><li>Most bradycardias respond to </li></ul><ul><ul><li>Oxygen </li></ul></ul><ul><ul><li>Ventilation </li></ul></ul><ul><li>For bradycardia 2 o to hypoxia/ischemia, preferred first drug is epinephrine </li></ul>

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