drugs used in sick children

1. FOREIGN BODY ASPIRATION

2.  90% of death in FBAO less than 5 years
 65% are infants
 Toys ballons or small objects round candies , nuts and grapes
Symptoms
Sudden onset of respiratosy Distress
Weak or silent coughing
Inability to speak
Stridor
Increased respiratory difficulty
Epiglottitis /Croup
Fever
Signs of congestion
Hoarsness
Drooling
Lethargy
Limpness
Gradual onset

3. FBAO
 Able to recognise and relieve severe or complete FBAO
 THREE MANEUVERS
 Back blows
 Chest thrusts
 Abdominal thrusts
 Impacted food
 Eating or Playing
 Usually witnessed/ conscious and responsive

4. Critical Concepts
UNIVERSAL CHOKING SIGN
INABILITY TO SPEAK
WEAK OR INEFFECTIVE COUGH
HIGH PITCHED SOUND OR NO SOUND
INCREASED DIFFICULTY IN BREATHING
CYANOSIS
NO NEED TO ACT IF VICTIM ABLE TO
SPEAK OR COUGH FORCEFULLY
IF OBSTRUCTION PERSIST SEEK HEALTH
CARE SUPPORT

5. Critical Concepts
Infant Child
Back blows Abdominal thrust
Chest thrusts
Abdominal thrusts not recommended less
than 1 year

6. Critical Concepts
DO NOT interfere if the infant coughing
Do not perform tongue jaw lift or attempt
to reach in the mouth of responsive
choking victims
Do not press on xiphoid process
Do not perform blind sweeps in infants
and children

8. PALS MEDICATIONS

9. Adenosine SVT 1st dose = 0.1 mg/kg rapid IV push to max of 6 mg.
2nd dose = 0.2 mg/kg rapid IV push to max of 12 mg
Atropine Symptomatic
bradycardia,
toxins and
overdoses
Bradycardia: 0.02 mg/kg IV with 0.5 mg max dose may repeat one time
By ET tube: 0.04-0.06 mg/kg
Toxins/overdose: 0.02-0.05 mg/kg repeated every 20-30 minutes until
symptoms reverse

10. Epinephrine Anaphylaxis, asthma,
symptomatic
bradycardia, croup,
shock, cardiac arrest,
toxins or overdose
Anaphylaxis: 0.01 mg/kg every 15 minutes to max of 0.3 mg
Asthma: (1:1000) 0.01 mg/kg subcutaneous every 15 minutes to max 0.3
mg
Symptomatic bradycardia: 0.01 mg/kg IV every 3-5 minutes to max
dose of 1 mg
Croup: 0.25 ml Racemic epi solution via nebulizer
Cardiac arrest: 0.01 mg/kg (1:10000) IV or 0.1 mg/kg (1:1000) per ET
tube every 3-5 minutes
Shock: 0.1-1 mcg/kg/ minute IV infusion
Albuterol Asthma,
bronchospasm,
hyperkalemia
2.5 mg if weight <20 kg
5 mg if weight >20 kg
Calcium
chloride
Hypocalcemia,
hyperkalemia;
consider for calcium
channel blocker
overdose
In cardiac arrest: 20 mg/kg IV bolus into central line
In non-arrest: infuse over 30-60 minutes

11. Dexamethasone Croup asthma 0.6 mg/kg for one dose (max dose 16 mg)
Dextrose Hypoglycemia 0.5-1 g/kg
Calcium chloride Hypocalcemia, hyperkalemia;
consider for calcium channel
blocker overdose
In cardiac arrest: 20 mg/kg IV bolus into central
line
In non-arrest: infuse over 30-60 minutes
Dobutamine
Ventricular dysfunction 2-20 mcg/kg/ minute infusion
Dopamine Ventricular dysfunction,
cardiogenic or distributive shock
2-20 mcg/kg per minute infusion titrated to
response

12. Furosemide Pulmonary edema,
fluid overload
1 mg/kg IV or IM to max dose of 20
mg
Hydrocortisone Adrenal insufficiency associated
septic shock
2 mg/kg IV bolus to max dose of
100 mg
Ipratropium Asthma 250-500 mcg every 20 minutes via
nebulizer for 3 doses
Norepinephrine Hypotensive shock 0.1-2 mcg/kg/m titrated to desired
BP
Sodium bicarbonate Severe metabolic acidosis,
hyperkalemia,
tricyclic overdose
1 mEq/kg slow IV bolus to max of
mEq
For overdose 1-2 mEq/kg bolus
repeating until pH >7.45 follow
infusion of sodium bicarb solution
to maintain alkalosis

13. Focus on Breathing

14. Check breathing
 Look
 Listen
 Feel
 Difficult to determine
 Rescue breathing
10 seconds

15. Recovery postion
 Maintain patent airway
 Cervical spine stability
 Minimize risk of aspiration
 Limit pressure on bony
prominence / nerves
 Able to observe childs
breathing
 Color
 Able to provide
intervention

16. Rescue breathing
 Head tilt chin lift
 Remove any visible
obstruction
 Sufficient volume
 Use devices if available
• Provide 2 effective breaths
• Use ventilation adjuncts
and oxygen
• Be sure the chest rises
with each breath

17. Rescue Breathing without barrier devices

19. Rescue Breathing with barrier devices
 Rescue breathing with a face shield
 Rescue breathing with a mask

20. Bag – Mask ventilation
 Requires more skill than mouth to mouth
 Appropriate mask and bag
 Opening the airway / securing the airway
 Delivering adequate ventilation
 Assessing the effectiveness of ventilation
250
500
750
• Rescuer should use
adequate force and
tidal volume
• Adequate chest rise
• Harmful effects
• Goal of ventilation
• Selection BM
• E-C Clamp technique
• Two rescuer

21. RESUSCITATION DEVICES ,
CHEST COMPRESSIONS AND
ET INTUBATION

23. The Golden minute
 The “first minute after birth”
 Anxiety for parents, health providers
 Period of transition from intrauterine to extra uterine life
 Major: No/minimal assistance
 10%: assistance to begin breathing at birth
 1%: extensive resuscitative measures
 First Golden Minute Project: skill based training

24. Endotracheal tubes (size 2.5-3.5) and blades (Miller
00,0,1)
Tape, scissors, suction supplies (5/6, 8, 10 F),
meconium aspirator
Varying sized masks (premie, normal)
Pulse ox probe
Bulb syringe
Warm blankets
ETT holders and ETCO2
Medication box (nurse), umbilical cord clamp
UVC kit (Nurse will bring)
Surfactant if anticipated use
Ventilator, CPAP…

29. Weight ETT size
<1.0 Kg 2.5
1.0-2.0 Kg 3.0
2.0-3.0 Kg 3.5
>3.0 Kg 4.0

31. Nals drugs
 Epinephrine
 VOLUME EXPANSION

33.  Why babies born preterm are at higher risk of medical
 complications
The additional resources needed to prepare for a preterm birth
Additional strategies to maintain the preterm baby’s body
 temperature
How to assist ventilation when a preterm baby has difficulty
 breathing
Additional considerations for oxygen management in a preterm
 baby
Ways to decrease the chances of lung and brain injury in preterm
 babies
Special precautions to take after the initial stabilization period
How to present information to parents before the birth of an
 extremely premature baby

34.  Thin skin, decreased subcutaneous fat, large surface area relative to
 body mass, and a limited metabolic response to cold lead to rapid
 heat loss.
 • Weak chest muscles and flexible ribs decrease the efficiency of
 spontaneous breathing efforts.
 • Immature lungs that lack surfactant are more difficult to ventilate
 and are at greater risk of injury from PPV.

35.  Immature tissues are more easily damaged by oxygen.
 • Infection of the amniotic fluid and placenta (chorioamnionitis) may
 initiate preterm labor, and the baby’s immature immune system
 increases the risk of developing severe infections such as
 pneumonia, sepsis, and meningitis.
 • A smaller blood volume increases the risk of hypovolemia from
 blood loss.
 • Immature blood vessels in the brain cannot adjust to rapid changes
 in blood flow, which may cause bleeding or damage from
 insufficient blood supply.
 • Limited metabolic reserves and immature compensatory
 mechanisms increase the risk of hypoglycemia after birth

36. NALS DRUGS

37. NALS DRUGS
 Very little role of medications during neonatal resuscitation. Only agents used
are Epinephrine and Normal saline
If the heart rate is less than 60 bpm
despite administration of adequate
ventilation and chest compressions
for 45-60 sec with 100% oxygen, give
medications

38. Adrenaline
Epinephrine is available as 1ml
ampoule of 1:1,000
concentrations, however
for neonate take one ml of
1:1000 solution and add 9 ml of
normal saline.
This makes 10 ml of 1:10,000
concentration
The dose of
Epinephrine when
given endotracheally
needs to be higher
(0.5 to 1.0 ml /kg or
0.05 to 0.1 mg/kg).
60
60
repeat the
dose every
3 to 5
minutes.

39. Volume Expander
If the baby appears to be in shock
and is not responding to
resuscitation, administration of a
volume expander may be
indicated
• 0.9% NaCl
(“Normal saline”)
• Ringer’s lactate.
• O Rh-negative
packed red blood
cells

40. O2

41. PRETERM RESUSCITATION
 Why babies born preterm are at higher risk of medicalcomplications
 The additional resources needed to prepare for a preterm birth
 Additional strategies to maintain the preterm baby’s body temperature
 How to assist ventilation when a preterm baby has difficulty breathing
 Additional considerations for oxygen management in a preterm baby
 Ways to decrease the chances of lung and brain injury in preterm babies
 Special precautions to take after the initial stabilization period

42. Why babies born preterm are at higher risk of
medical complications?
 Underlying problem that caused the preterm birth/ baby’s anatomic and
physiologic immaturity.
 Thin skin, decreased subcutaneous fat, large surface area relative to
body mass,
 Weak chest muscles and flexible ribs
 Immature lungs that lack surfactant
 Immature tissues are more easily damaged by oxygen
 Infection
 Risk of hypovolemia
 Immature blood vessels in the brain
 Limited metabolic reserves and immature compensatory mechanisms

43. The additional resources needed to
prepare for a preterm birth
 Anticipate
 Hypothermia –plastic wrap
 Oxygen blender / oximeter
 ECG monitor
 T-piece resuscitator or flow-inflating bag,
 A preterm-sized resuscitation mask, size-0 laryngoscope Blade (size 00
optional), and appropriate-sized endotracheal tubes (3.0 mm and 2.5 mm)
 Surfactant
 A pre-warmed transport incubator

44. How do you keep the preterm newborn
warm?
 Increase the temperature in the room where the baby will receive
 initial care. Set the room temperature to approximately 23oC to
 25oC (74oF to 77oF).
 Preheat the radiant warmer well before the time of birth.
 Place a hat on the baby’s head.
 For babies born at less than 32 weeks’ gestation,*

45. How do you assist ventilation?
 apnea, gasping, or heart rate ,100 bpm within 60 seconds of birth despite the
initial steps).
 If the baby has labored respirations or oxygen saturation remains below the
target range, CPAP may be helpful

47. RECOGNITION &
MANAGEMENT OF
BRADYCARDIA

48.  Bradycardia is a heart rate slower than normal for the child’s age and activity level
 In the pediatric population, a heart rate less than 60 beats per minute is an
ominous sign and CPR should be initiated immediately
 Primary
 Secondary

51. Bradycardia
identified
Look for the cause
Do not delay
Establish airway
Assist breathing if
necessary
Monitor HR and
Rhythm, BP
Establish IV /IO
Access
Continue monitor
call for consults
Ephinephrine
Atropine
Hypotension
or Shock
Hypoxia
Acidosis
Hyperkalemia
Hypothermia
Heart block
Toxins
Trauma
If atropine not
effective
Consider pacemaker

52. RECOGNITION AND MANAGEMENT OF
PAEDIATRIC TACHYCARDIA
 Tachycardia is a faster than normal heart rate for the child’s age and activity level
 Classified as narrow QRS complex (QRS <0.09 seconds) or wide QRS complex
(QRS >0.09 seconds).

53. System Sinus Tachycardia SVT VT
Onset Commonly associated with
pain, fever, hemorrhage or
dehydration; ST is gradual in
onset
Sudden often with palpitations Sudden but uncommon in
children unless associated
with an underlying
condition
Airway patency Not affected Not affected Not affected
Respiratory rate and
effort
Faster than normal Faster than normal often with
rales and wheezes; increased
work of breathing
Faster than normal
Systolic BP Variable Usually lower than normal Variable
Heart rate Infant <220/minute
Child <180/minute
Rate typically increases with
activity or severity of illness
Infant >220/minute
Child >180/minute
Rate not affected by activity
Greater than 120 beats per
minute and regular

54. ECG characteristics Narrow QRS complex; P
waves normal; PR interval
constant; R-R interval may be
variable
Narrow or wide QRS complex; P
waves absent or abnormal; R-R
interval may be constant
Wide QRS complex; P
waves may not be present
or seen; QRS complexes
may be uniform or variable
Peripheral pulses Normal Weak Weak
Capillary refill Normal Increased time to pink Increased time to pink
Level of
consciousness
May be light-headed or dizzy Diminished level of
consciousness; dizzy, light-
headed
Diminished level of
consciousness; dizzy, light-
headed

56. Attempt to identify
cause do not delay
Support ABCs
Maintain SPO2
Hypotension ,
decreased LOC , Shock
, Chest pain
SynchronisednCardioversion Establish IV or IO
Consider Adenosine
QRS Narrow and
Regular 50-100
QRS narrow and
Irregular 120-200
QRS wide and
regular 100
QRS wide and
irregular Defibrill
Stable

59. Cardiac arrest

60.  Cardiac arrest is the absence of circulation and pulses caused by ineffective or
absent cardiac activity.
 In cardiac arrest, the child is pulseless and unresponsive and breathing is absent or
gasping.
 Cardiac arrest in children is typically hypoxic or asphyxial arrest as a result of
respiratory distress or shock. Sudden cardiac arrest (SCA) is less common in
children and is typically caused by VF or pulseless VT.

61.  Asystole (cardiac standstill or flat line) is the absence of any electrical activity on the ECG.
 Pulseless electrical activity (PEA) is defined as any rhythm with electrical activity on the ECG
without palpable pulses in the patient.
 Ventricular fibrillation (VF) is seen as unorganized, chaotic electrical activity on the cardiac monitor
with no palpable pulses in the patient. VF is one of the “shockable” rhythms.
 Pulseless ventricular tachycardia (VT) is seen on the monitor as an organized rhythm with wide
QRS complexes and no pulses in the patient. The danger of pulseless VT is that it will deteriorate
into VF. Typically, VT is more readily converted than VF so it is critical to treat pulseless VT quickly

62.  The period of time between collapse and CPR: Better outcomes will be realized if there is a shorter interval
between collapse and CPR.
 The provision of high-quality CPR: Hard and fast is the most effective.
 The duration of CPR efforts: In general, the longer CPR continues, the worse the outcome.
 Underlying causes: Early intervention for reversible causes of arrest can improve outcomes