This document summarizes guidelines for pediatric cardiopulmonary resuscitation (CPCR) presented by Dr. Sunil Mokashi. It discusses differences between pediatric and adult cardiac arrest, including causes and rhythms. It provides guidance on basic life support techniques for infants and children, including chest compression methods and ventilation ratios. The document also reviews pulseless arrest algorithms, including defibrillation doses and use of epinephrine. Pediatric bradycardia and tachycardia treatment are also summarized. The presentation aims to outline best practices for resuscitation of children in both pre-hospital and hospital settings.

1. Dept of Anaesthesia,Govt TDMC,Alleppy. Date:14-10-2014
 PEDIATRIC CPCR
 NEONATAL CPCR
 CPCR IN SPECIAL CONDITIONS
Presenter : Dr Sunil Mokashi
Senior Resident, Anaesth Dept
Govt TDMCH, Alappuzha.688005
Moderater : Dr Santhosh S.

2.  New born -------------- <4 wks
 Infant -------------------- 4 wks-1 year
 Child ---------------------- 1 yr -14 yrs
 Adult -------------------- >14 year

3. INTRODUCTION
*Pediatric cardiopulmonary arrest differ from adult cardiac
arrest i. e,
1.Adults’ cardiac arrest d/t CAD with severe ischemia and precip-n
of malignant arrhythmia, where as children relatively have
normal coronary arteries and primary cardiac arrhythmias are
uncommon.
2.Initial respiratory compromise/arrest f/b secondary cardiac
arrest is common in pediatric age groups.
3. Adults usually display ventricular arrhythmias, w/a children
more likely to have bradyarrhythmias that degenerate into
asystole.

4. 4.Autonomic nervous system has predominant
parasympathetic vagal tone at birth gradually shifts to
sympathetic tone in older children.
5.Frank starlings mechanism is less effective in new born, so
cardiac output greatly depends on Heart Rate in neonates
and children.

5. Mechanisms of cardiac arrest in pediatric age group. .
1. Respiratory failure[ asphyxial arrest]
Asphyxia begins with variable period of systemic hypoxemia
Hypercapnea & Acidosis
Bradycardia and Hypotension
Cardiac arrest
2.Another mechanism - Ventricular Fibrilation /pulseless
VT in 5 % 15% of pediatric group. Incidence of both VF and
pulseless VT increases with age.
3.Genetic abnormalities in cardiac myocites -> abnormality in
ionic flow - >
-> sudden cardiac arrest.

6. BLS considerations
 BLS defn- Basic life support is the level of medical care which is used
for the life threatening illnesses or injuries until they can be given full
medical care @ hospital.
 BLS provided by emergency medical technicians,paramedics,
laypersons in prehospital setting can b provided without medical
equipment
 AHA considers CAB[ circulation, airway, breathing], during BLS.

7. WHO CAN GIVE BLS ?
Any body from the public or the people in the vicinity
of child who has undergone arrest, can start BLS -CPR..!
including us.

8. PALS defn: Refers to the assessment and support of
pulmonary and circulatory and cerebral function in the
period before an arrest, during and aft an arrest.
 Consistant with Chain of Survival ,PALS should focus on
prevention of causes of cardiac/ respiratory arrest( sids
,injury,chocking) and early detection and rapid Rx of
cardiopulmonary compromise and arrest in critically ill or
injured child.

9.  Continuation of BLS
 Circulation by cardiac massage/compression
 Airway by guedel’s..
 Breathing by advanced methods….ET
tube,LMA,combitube,tracheostomy
 Defibrillation manually
 Drugs
 Dd---…search for reversible cause
PALS takes place- organised healthcare environment,
multiple trained cpcr providers, ie , critical care
physicians/ respiratory therapists/ pediatricians/
anesthetists/critical care nurses.

10. PALS

11. Survival rates from pediatric resuscitation[ in hospital cardiac
arrest [ infants and children]
1985 - 9%
2000 - 17%
2006 - 27%
2010 - 34%
 70% survival rates- in Rapid and effective bystander CPR, with
ROSC & neurologically intact survival in children [ out of
hosp cardiac/resp arrest]
 Bystander CPR- 20 to 30 % survival in VF [out of hosp arrest]
contd. . . .

12. Type of cardiac arrest % of survival [in hosp arrests]
1. VF/ Pulseless VT - 34% (survival to discharge)
2. Pulseless E A - 38% , ,
3. Asystole - 24% , ,
4. Infants and children with
pulse but poor perfusion
& bradycardia who required - 64 %
cpr.
Source-pediatric data National Registry of Cardiopulmonary
Resuscitation
[NRCPR-2008]

13. Pediatric BLS
ABC or BAC ?
The 2010 AHA guidelines recommend CAB sequence, ie.
Chest compressions
Airway
Breathing / Ventilation
During cardiac arrest a high quality CPR particularly essential to
generate,
blood flow to vital organs and ROSC.

14.  Infant BLS guidelines apply- to infants less than 1 yr of age.
 Child BLS guidelines- children from 1yr to puberty.
 Adult BLS guidelines -At puberty and beyond.
 Asphyxial cardiac arrest is more comon than VF cardiac arrest in
infants and children , so ventilations are extremly important in
pediatric
resuscitation.

15. BLS Sequence for Lay Rescuers
1. Assess the need for CPR.
>Lay rescuer should assume that CARDIAC ARREST is
present
if the victim is UNRESPONSIVE.
2. Check for response.
> Gently tap the victim and ask loudly “ Are you okay ?”
>Look for any injuries and if child needs medical assistance.
>If child is responsive and breathing- leave child and activate
Emergency Response System.
> If child unresponsive - shout for help.
Contd….

16. 3. Check for Breathing
>If breathing regular and victim does not need CPR
No evidence of trauma
Turn child into recovery position( maintain patent airway
and decrease risk of aspiration)
> If child is unresponsive, not breathing/ Gasping
Start CPCR
4. Start chest compressions -
Push fast - 100 chest compressions per min
Push hard- push atleat 1/3 rd AP diameter of chest
contd…..

17.  Depth of chest compression-
infant- 1 .1/2 inchs or 4cm
children- 2 inches/ 5cm
Things to be kept in mind while giving CHEST COMPRESSION
> Allow complete chest recoil after each compression to allow the
heart to refill with the blood.
> Minimise interuruptions of chest compression .
> Avoid excessive ventilation.

18. 5. Open airway and give ventilations :
> A compression to ventilation ratio of 30: 2 recommended.
> Open airway by Head tilt - Chin lift maneuver for both
injured and non injured pt’s.
> In infants Mouth to Mouth and Mouth to Nose technique for
giving
breaths
> If difficult in making effective seal, use,
1. Mouth to mouth techn- pinch nose.
2.Mouth to nose technique – close mouth

19. Coardinate chest compressions and breathing:-
After 2 effective breaths
30 compressions immediately
Continue the cycles for 2 min /5cycles before leaving the victim to
activate
Emergency Response System to obtain AED.
Rescuer should return to victim as soon as possible use either AED
or start CPR
Continue the cycles of 30 chest compressions to 2 ventilations until
ERS

20. Fig: Pediatric Chain of Survival
showing , 1.early CPR,
2 early EMS actvn,
3. AED cardioversion
4 . Tranport for early PALS,
5. PALS
6. additional links- definitiv care
and rehabilitation of child.

21. BLS sequence for Health Care providers
 BLS health care providers work in team
 Unlike layperson guidelines, Chest compressions and securing airway
for rescue breathing happen simulteneously.
 Health care providers should focus mostly on cause of arrest in child
and act accordingly.
Ex: If health care providers witness, a arrest or sudden collapse in an
adolescent or a child( child identtified tto b at risk of arrhytthmia or
in
athletic event), the HCP may assume that victtim has suffered a
sudden VF,-cardiac arrest. As soon as rescuer verifiesthe child is
unresponsive
& not breathing(even gasping) ,then he should phone ERS get AED,

22. BLS STEPS
1.Asssess the Need for CPR:
Unresponsive ,nonbreathing, gasping individual, send
some
one to activate Emergency Response System
2. Check pulse :
10 seconds only to check pulse
brachial - infant , carottid or femoral -> child
Absent pulse/ difficulty in feeling pulse -> begin chest compressions

23. BLS STEPS
3. Inadequate Breathing with pulse.
Pulse ≥ 60 but no adequate breathing
rescue breaths 12 to 30 breaths per min till spontaneous
breathing
resumes
Reassess pulse every 2 min (assess in < 10 seconds)

24. Bradycardia with poor Perfusion:
pulse <60 pm & signs of poor perfusion + despite support with
oxygenattion and ventilations
begin chest compressions
Because infants and children largely depend on heart rate .
Profound bradycardia (< 60 witth signs of poor perfusion )is
indication for
chest compressions and CPCR

25. Chest Compressions.
Child unresponsive / not breathing / no pulse
Start Chest compressions.
Types:
1. Two finger chest compression for infants
2. Two thumb encircling hand technique- Recommended when
CPR provided by 2 rescuers
The ‘2 thumb encircling hands technique ‘ preferred over
Two finger technique- because former produces ,Higher
coronary
artery perfusion pressure and adequate depth of chest
compression.

26. Two finger technique of chest compression

27. Two thumb encircling hands technique of chest
compression ( two rescuers)

28. # 30 compressions (15 compressions if two rescuers)
# Open airway with head tilt and chin lift and give 2 breaths
# use head tilt ,chin lift maneure if jaw thirst is not opening airway
Coordinate chest compressions:
Lone rescuer- 30:2 and 2 rescuers - 15 : 2.
100 compresssions per min
8 to 10 breaths per min and abreath every 6 to 8 seconds
Ventilations:

29. Defibrillation:
Shockable rhythms- VT and Pulseless VT
AEDs are equipped with attenuation of energy delivered
,that is required in chil
Dose of first shock - 2J/kg
Dose of 2nd shock- 4J/kg
AED wil prompt rescuer to re analyse the rhythm every 2
min
Shock delivery should occur as soon as possible after chest

30. BAG and MASK Ventilation
 Prefered – EC clamp technique of bag – mask ventilation
 Self inflating bag with 450- 500 ml volume can b used.
 To deliver high O2 concentration(60% to 95%) attach oxygen
reservoir to
self inflating bag
 Maintain O2 flow rate of 10 to 15 L/min into reservoir attached to
pediatric bag
 Avoid excessive ventilation
 Pt with airway obstruction or poor lung compliance require high
inspiratory pressure.

31. Two person Bag Mask Ventilation
>helpful when significant airway obstruction, poor lung
compliance ordifficulty in creating tight seal b/n mask and
face.
> one person holds mask and create tight seal, other gives
bag compressions

32. EC clamp technique of holding bag and mask for ventilation
Thumb and indexfinger on
either side of mask to make
‘c’ and holding mask againt
pt mouth,f/b using other 3
fingers to lift the angle of jaw
fingers forming ‘ E’

33. Airway adjuncts
Oropharyngeal airways
Nasopharyngeal airways
Cuffed oropharyngeal airways

36.  ENDOTRACHEAL TUBE PLACEMENT
 ET intubation - indicated at several points during
neonatal resuscitation:
1. Tracheal suctioning for meconium
2. Bag-mask ventilation is ineffective / prolonged
3.When chest compressions are performed
4.When ET administration of medications is required
5.Congenital diaphragmatic hernia or extremely low birth
weight (<1000 g)

37. Place a pillow under the head and neck but NOT under the
shoulders
This allows a straight line of vision from the mouth to the
vocal cords
The laryngoscope is introduced into the right hand side of
the mouth (it is held by the left hand

38.  The tongue is swept to the left and the tip of the blade is
advanced until a fold of skin / cartilage is visualised at
twelve o’ clock
 This is the epiglottis, and this sits over the glottis (the
opening of the larynx) during swallowing

39.  The tip of the blade is advanced to the base of the
epiglottis, known as the vallecula, and the entire
laryngoscope is lifted upwards and outwards
 This flips the epiglottis upwards and exposes the glottis
below
 An opening is seen with two white vocal cords forming a
triangle on each side

40.  The tip of the ET tube is advanced through the vocal
cords and once the cuff has passed through, one stops
advancing The tube is secured at this level and the cuff
inflated

44. PEDIATRIC CPCR
American Heart Association guidelines [2010 ]
for PALS
[Pediatric Advanced Life Support]

45.  Pulseless cardiac arrest:
 When child is unresponsive with no breathing , get an
AED/manual defib
-rillator
 High quality CPCR should be given throughout
rescuscitation.
 Determine cardiac rhythm by ECG. And decide
shockable or non shockable like Asystole or pulseless

46.  Non Shockable rhythm : Asystole /PEA
 PEA defn- It is organised electrical activity most commonly slow and
wide QRS complexes without palpable pulse
 Another entity- EMD( Electro Mechanical Dissociation) -> there is
sudden impairment of Cardiac output with an initially normal
rhythm
 EMD is more reversible than Asystole

47.  FOR Asystole and PEA
> Continue CPCR with less interruptions to chest compressions
Another rescuer gives Epinephrine aft IV/IO access @0.01mg/kg
(0.1 ml/kg of 1: 10 000 solution) & Dose repeated every 3 to 5min
With advanced airway in place one should give chest compressions
100/min without pause for ventilation.
second rescuer delivers 1 breath every 6 to 8 sec(8 to 10 breaths per
min)
Check rhythm every 2min,if rhythm nonshockable continue CPCR
& Epinephrine admn. Till there is evidence of ROSC
If rhythm becomes shockable deliver shock. Search for and treat
reversible causes.

48. PEA
Asystole

49.  Shockable Rhythm. (VF/pulseless VT).
 Defibrillation is definitive treatment of choice for VF with overall
survival of 17% to 20%
 AED or manual defibrillators can b used for delivering shocks
 Paddle size of defibrillator wil b
Adult size (8 to 10 cm ) for children > 10kg(Aproximatly 1 yr)
Infant size for infants<10 kg

50. Paddle position :
For AED or moniters /defibrillator pads follow package
directions
For manual pads place one pad over rt side of upper chest
and another at the apex of the heart (to the left of the
nipple over left
lower ribs)

51. VF and pulseless VT)

54.  Energy Dose.
 For VF – dose of 2 to 4 j/kg.
 In refractory cases- 4J/kg and susequent doses should b
atleast 4J/kg
Higher energy levels must be considerd but not to exceed
10J/kg

56. Pediatric Bradycardia-
> Emegency Rx of bradycardia indicated when it results into
hemodynamic
changes.
> Support airway breathing and circulation, of pulses perfusion and
respirations are adequate no emergency Rx required.
> If bradycardia is <60bpm with poor perfusion continue to support
airway ,ventilation, oxygenations and chest compressions.
if bradycardia persists /transiently responding, give Epinephrine
IV/IO
0.01mg/kg bw(0.1 ml/kg of 1:10000 solution)
> If bradycardia is due to increased Vagal Tone or primary AV

58.  Pediatric Tachy cardia
 Signs of poor perfusion and nonpalpable pulse-> proceed to pulseless
arrest algorithm.
 +ve pulse with poor perfusion
> assess and support BAC
> provide O2
>Attach monitor/defibrillator
>obtain vascular access
>Evaluate 12 lead ECG and assess QRS duration
 Narrow complex (< 0.09 second) Tachycardia:
> 12 Lead ECG pts clinical presentation and history wil
help to differentiate sinus tachycardia from SVT

59.  Supraventricular Tachycardia
> Monitor rhythm and degree of hemodynamic instability
> Attempt vagal stimulation – apply ice to face in infnts and young
children without occluding airway.
> In older children carotid sinus massage or valsalva maneurs are
safe.
> Pharmacological cardioversion - Adenosine DOC.
adenosine 0.1 mg/kg IV/IO should be given rapidly
and flushed with > /= 5ml normal saline.
> Verapamil 0.1 – 0.3 mg/kg IV/IO effective in terminating SVT,
should not be used in infants since can cause potential myocardial
depression, hypotension and cardiac arrest

60. SVT contd…
> If Pt is hemodynamically unstable- sync cardioversion
start with 0.5 to 1 J /kg then increase the dose i to 2J/kg durind
2nd shock.
> If 2nd shock unsuccessful – consider Amiodarone-5mg/kg IO/IV or
procainamide 15 mg/kg IV/IO.
> Both amiadarone and procainamide should be given with slow
infusion at the rate of over 20 to 30 min (amiadarone) and 30 to 60
min( procainamide)under expert consultation.
> Should moniter ECG and BP during infusion. If no effect or no signs
of toxicity give additional doses

61. Wide Complex ( > 0.09 second) Tachycardia
# Originate in ventricle (ventricular tachycardia) but may be
Supraventricular in origin.
# Adenosine may be helpful in differentiating SVT from VT and
converting
wide complex tachycardia of supraventricular origin .
# Adenosine should be considered – if rhythm is regular and QRS
complex is monomorphic.
# Do not use adenosine in patients with Wolf – Parkinson White
Syndrome
Contd. .

62. # Consider electric cardioversion after sedation using energy dose of
0.5 to 1 J /kg If that fails increase the dose to 2J/kg
# Consider pharmacologic conversion with IV amiadarone(5mg/kg
over 20 to 60 min) or procainamide ( 15mg/kg given over 30 to 60
min) with ECG and BP monitoring
Stop and slow the infusion if there is decline in BP/QRS widens
# In hemodynamically unstable pts - Electric Cardiversion .
0.5 J/kg in 1st shock then increase to 2J/kg susequently.

64. Torsades Pointes-
 Type of polymorphic VT associated with long QT interval
may be congenital or due to toxicity with type 1A antiarrhythmics
( procainamide, quinidine,and disopyramide) ,type III
(sotolol,amiadarone) TCA’s digitalis ‘drug interactions.
Rx:- #This rapidly converts to VF or Pulseless VT.
#Initiate CPCR proceed to defibrillation when pulseless arrest
develops.
#treat Torsades pointes with rapid infusion of MgSo4 @ dose of
25- 50mg/kg; max single dose-2gm)

65. In different situations
# Septic shock-
> crystalloid is prefered initial fluid of choice than colloid.
> Monitoring central venous O2 saturation(ScvO2) useful to
titrate the therapy in infants and children with septic shock.
Target therapy of
ScvO2 >/= 70% improve pt survival in severe sepsis.
> Early assisted ventilation may b considered as part of protocol
driven strategy in septic shock.
> Etomidate known to facilitate ET Intubation in infants and
young children
Caution: Etomidate should not be used routinely in pediatric
patients

66. Hypovolemic shock
 Use of crystalloids RL or NS as initial fluid is recommended
 No role of adding colloid in early phase of resuscitation
 Rx signs of shock with bolus of 20 ml/kg crystalloid even if BP
normal.
 Crystalloids have survival benefit over colloids for children with
general trauma ,traumatic brain injury, and burns.
 Additional boluses (20ml/kg) of crystalloids is given if systemic
perfusion
fails to improve.

67. NEONATAL RESUSCITATION

68. ANTICIPATION/ RISK FACTORS
Maternal
• Prolonged rupture of membranes (greater than
18 hours)
• Bleeding in second or third trimester
• Pregnancy induced hypertension
• Chronic hypertension
• Substance abuse
• Drug therapy (e.g. lithium, magnesium,
adrenergic blocking agents, narcotics)
• Diabetes mellitus
• Chronic illness (e.g. anaemia, cyanotic congenital
heart disease)
• Maternal pyrexia
• Maternal infection
• Chorioamnionitis
• Heavy sedation
• Previous fetal or neonatal death
• No prenatal care

69. Fetal-
Multiple gestation (e.g. twins, triplets)
Preterm gestation (especially less than 35 weeks)
Post term gestation (greater than 41 weeks)
Large for dates
 Fetal growth restriction
Alloimmune haemolytic disease (e.g. anti-D, anti-Kell,
especially if fetal anaemia or hydrops fetalis present)
Polyhydramnios and oligohydramnios
Reduced fetal movement before onset of labour
Congenital abnormalities which may effect breathing,
cardiovascular function or other aspects of perinatal transition
Intrauterine infection
Hydrops fetalis

70. Intrapartum
 Non reassuring fetal heart rate patterns on
cardiotocograph
(CTG)
 Abnormal presentation
 Prolapsed cord
 Prolonged labour (or prolonged second stage of labour)
 Precipitate labour
 Antepartum haemorrhage (e.g. abruption, placenta
praevia,
vasa praevia)
 Meconium in the amniotic fluid
 Narcotic administration to mother within 4 hours of
birth
 Forceps birth

71. 2010 American Heart Association Guidelines for
Cardiopulmonary
Resuscitation and Emergency Cardiovascular
Apply primarily to newly born infants undergoing transition
from intrauterine to extrauterine life
Also applicable to neonates during the first few weeks to
months following birth.

72. Approximately 10% of newborns require some
assistance to begin breathing at birth.
Less than 1% require extensive resuscitative
measures.

73. INITIAL ASSESMENT
• Term gestation
• Crying or breathing
• Good muscle tone

74. If ‘YES’; no resuscitation
Baby
Dried
Covered with dry linen
Placed close to the mother
Monitor breathing,activity
and colour

75. If ‘NO’-
Resuscitation
A. Initial steps
B. Ventilation
C. Chest compressions
D. Medications or volume expansion
E. Post resuscitation care

77. Initial steps
Provide warmth
Sniffing position
Dry the baby
Stimulate breathing
Clear airway( if needed)

78. Initial steps(temperature control)
Important for very LBW(<1500g) preterm
babies
Radiant heat
Exothermic mattress
Covering with heat resistant plastic
Pre warming delivery room to 26 degrees
temp monitored closely

79. Initial steps(clearing the airway)
•Immediate suctioning following birth
Obvious obstruction to spont
breathing
Require PPV
•No routine nasopharyngeal or
oropharyngeal suctioning
•Nasopharyngeal suctioning can create
bradycardia
Endotracheal suction of nonvigorous
babies with MSAF(meconium stained
amniotic fluid )

80. Initial steps(stimulate breathing)
•Rub the baby’s abdomen or back up and
down
•Flick the underside of the baby’s foot with
your fingers.

81. Suctioning the airway
 Mouth 1st then nose
 Gentle and intermittent
 Bulb syringe , de Lee suction
 2 to 3 sec
 Depth of suction about 3 inches/7cm
 No aggressive suction
 Electrical suction : negative pressure < 100mm
Hg
 Aggressive throat suction can cause mucosal
trauma and stimulation of posterior pharynx
leading to vagal stimulation, bradycardia and
laryngospasm

83. Golden minute
Approximately 60 sec for initial
steps,
re-evaluation and beginning B

85. After initial steps
Assess simultaneously
1. Heart rate - > or < 100 beats/min
2. Respiration – apnea, gasping, labored
or unlabored breathing

86. Heart Rate
Primary vital sign to judge need and
efficacy of resuscitation
Auscultate precordium(better and most
accurate)
Palpation of the umblical pulse

87. Positive pressure ventilation
Ind: if infant after initial steps
Apneic
 gasping
H.R < 100/min
Provided by Bag mask
ventilation
Monitor SpO2

89. Ventilation
For term babies- ie > or = 37 wks
initiate resuscitation with room
air(21%)
Step up- based on H.R; if H.R < 60
after 30s of ventilation
supplementary oxygen- by blending
oxygen and air
Gradual step up to 100%
Guided by pulse oximetry

91. For preterm babies- ie < 32
weeks
initiate resuscitation with
blended oxygen and air
O2 conc between 30-90%
Guided by pulse oximetry
Titrate O2 conc accordingly
Ventilation

92. Rate – 40 to 60 breaths/min
Initial inflation pressure- 20 to 25 cm of H2O for
preterm and 30 to 40 cm of H2O for term
Target- H.R 100/min
PEEP likely to be beneficial in preterm
Monitor with CO2 detectors to identify airway
obstruction
Assisted ventilation

93. Evaluation after 30 seconds of ventilation
Heart rate
State of oxygenation
Respiration
Increase in HR most sensitive indicator of
resuscitation efficacy
Assessment once PPV started

94. If H.R < 100 & > 60
Take ventilation corrective steps
Assess chest wall movement

96. HR<60
Start chest compressions
Co-ordinate with PPV
Consider Intubation

98. Targeted SpO2 After Birth
1 minute 60 to 65%
2 minutes 65 to 70%
3 minutes 70 to 75%
4 minutes 75 to 80%
5 minutes 80 to 85%
10 minutes 85 to 95%
same for both term and preterm

99. Chest compressions
Ind: H.R < 60/min after vent with
supplementary O2 for 30s
Site- lower 3rd of sternum
Depth- one third of AP diameter of chest

100. Chest compressions
Ratio- 3:1
Rate- 90 compressions and 30
vent.s/min

102. Compressions and ventilations coordinated
Avoid simultaneous delivery
Chest allowed to reexpand fully during
relaxation
Thumbs should not leave the chest
Avoid frequent interruptions
Method-

103. With 2 thumbs- fingers encircling the chest
and supporting the back
With 2 fingers- 2nd hand supporting the back
2 thumb-encircling hands tech generate
higher peak systolic and coronary perfusion
pressure
Recommended in newly borns
Techniques

105. Medications and volume expansion
Ind- H.R < 60/min despite adequate ventilation with
100% O2 and chest compressions
Rarely indicated

106. Epinephrine
Dose- 0.01 to 0.03 mg/kg/dose
Conc- 1: 10000 Intravenous
0.05 to 0.1 mg/kg through ET tube

108. Volume expansion
Ind:
Blood loss
Suspected blood loss- pale
skin,poor perfusion,weak pulse
Inadequate H.R response to
resuscitation

109. Volume expansion
Isotonic crystalloid solution or blood
Dose: 10 ml/kg
Rate:
Intraventricular hemorrhage- rapid
infusions esp in premature infants

111. Assisted-Ventilation Devices
1. A flow inflating or self inflating bag
2. T- piece
3. LMA
4. ET tube

112. For newborns >2000g or delivered > or = 34 wks gestation
If face mask ventilation unsuccessful and tracheal intubation
unsuccessful or not feasible
Not in MSAF, during CPR and for drug administration
LMA

113. ET intubation
Indications:
•Initial endotracheal suctioning of nonvigorous
meconium stained newborns
•If bag-mask vent ineffective or prolonged
•During chest compressions
•Special resuscitation- Cong diaphragmatic
hernia or extremely LBW

114. Confirmation of ET tube placement- by exhaled CO2
detection
ET suctioning is recommended in nonvigorous babies with
MSAF
If intubation attempt prolonged or severe bradycardia
,consider bag-mask vent/PPV

115. The Endotracheal tube size
The Endotracheal tube size usually is 3.5 for term baby
and 2.5 for a preterm baby. A malleable but rigid stylet
may be introduced into the Endotracheal tube for ease
of intubation, But be careful not to cause trauma. The
tip of the stylet should not extend beyond the
Endotracheal tubeET Tube
size
Weight in
grams
Gestationa
l age
(Weeks)
2.5 <1000 28
3 1000-2000 28-34
3.5 2000-3000 34-38
4 >3000 >38

116. Nasal prongs
Nasal prongs are an
alternative way of giving
PPV

117. CPAP
May be administered to preterm infants
who breath spontaneously but with
difficulty
Advantage- reduce intubation,surfactant
use and durn of ventilation
Disadv- Pneumothorax

119. Post resuscitation care
Risk for deterioration
Close monitoring and anticipatory care
Avoid hypoglycemia; Glucose infusion- for
newborns with low blood glucose
Naloxone not routinely recommended even
if mother has opioid exposure
Induced therapeutic hypothermia-

120. Induced Therapeutic Hypothermia
Induced therapeutic hypothermia- whole
body or selective head cooling
Offered to infants born at >/= 36 wks
with evolving moderate to severe
hypoxic-ischemic encephalopathy
Start within 6 hrs following
birth,continue for 72 hrs and slow
rewarming over 4 hrs

121. Withholding Resuscitation
Extreme prematurity(gest age
< 23 wks or birth wt < 400g)
Anencephaly
Major chromosomal
anomalies( trisomy 13)

122. Discontinuation of resuscitation
H.R undetectable for 10 min
In situations of prolonged bradycardia with heart rate <
60 /min for > 10-15 min, there is insufficient evidence to
make recommendation regarding continuation or
discontinuation of resuscitation

123. Resuscitation
step
2005 2010
Assessment for
resuscitation need
4 questions 3
Airway Clear airway Assure open airway
No routine
suctioning
Assessment after
initial steps
H.R
Color
Respiration
H.R
Resp
Checking H.R By palpating
umblical cord
pulsations
Auscultating
precordium
Major changes in AHA guidelines

124. Ind.s for PPV H.R,apnea/gasping and
central cyanosis
Cyanosis out
Assessment once PPV
started
H.R
Color
respiration
H.R
Pulse oximetry
Respiration
Assessment of
oxygenation
Based on color
Pulse oximetry for only
< 32weeks with
need for PPV
Based on pulse
oximetry
for both term and
preterm
Target saturation Not defined defined
Initial O2 conc for PPV Term-Start with 100%
O2 during PPV
< 32wks-start with O2
conc between 21 and
100
Term-Start with room air
(21%)
<32 wks-O2 conc
between 30 and 90%

125. Initial breath strategy for
PPV
No specific PIP
recommendation
PIP- for initial breaths 20-
25 cm H2O for preterm
and
30-40 cm H2O for some
term babies
No specific
recommendation for
PEEP
PEEP likely to be
beneficial
for initial stabilization of
preterm infants
Guiding of PPV looking at
chest rise and
improvement
in heart rate
Guide the PPV looking at
heart rate and
oxygenation
especially in preterm,
chest
rise less reliable
Use of LMA For near term and term
infants >
2500g may be used
LMA may be used for
infants
>2000g and ≥ 34 weeks

126. Upper airway interface PPV by nasal prongs
superior to facial masks for
providing
Chest compression cardiac arrest is due
to a clear cardiac etiology
where ratio of 15:2 may
be
considered
Naloxone considered Not recommended
Therapeutic
Hypothermia
Not routinely
recommended
Recommended for ≥ 36
wks with moderate to
severe hypoxic ischemic
encephalopathy

127. Apgar Score
 Described first by an anaesthetist Virginia
Apgar in 1952,it still holds good for
assessing the baby’s condition and for
prognostication of the neurological status

128. •It is simple
•reproducible
•universally accepted
•popular score
•It is a simple useful guide to
neonatal well-being and
resuscitation
•Apgar Score

129. The first apgar score is assigned at 1 minute only and
hence the decision to start resuscitation cannot be
based on that. however, the apgar score at 5 minutes
is important to assess the effectiveness of
resuscitation.
If the score is 6 or less, then the baby should be
assessed again at 10, 15 and 20 minutes (Extended
Apgar score).
A low Apgar score at 10 minutes or later is associated
with a poor prognosis.
If the score is 3 or less at 15 minutes, the chance for
brain damage and cerebral palsy is >57%
Apgar scoring should continue every 5 min. until the
scoring is >7

130. Acronym observation 0 1 2
A Appearance (Color) Blue or pale Periphery blue Pink
P Pulse (Heart) rate Nil Less than 100 100
or
mor
e
G Grimace (reflex with
catheter in nostril)
No Response Grimace Cry
or
snee
ze
A Activity (muscle tone) Flaccid Some flexion of
limbs
Sem
i-
flexe
d:
activ
e
R Respiration Nil Slow, irregular Cryi
ng

131. Heart rate
Normal:120-160 beats/minutes
Max: 220 beats/minutes
< 100 beats means low cardiac output and poor
tissue perfusion
Cause
Usually asphyxiated neonates
Other causes CHD ,Congenital Heart block, and
congestive heart failure
Diagnosis
Prenatal ECG and echo cardiogram

132. Respiratory Efforts
 The respiratory rate is not considered only
the quality of respiratory effort
 Breathing usually begins by 30 sec. of extra
uterine life and sustained by 90 sec of Age
 Normal : 30-60 breaths /min
◦ There is no pause between inspiration and
expiration
◦ It helps to develop and maintain a normal FRC

133. Apnoea and Bradypnoea
Acidosis
Asphyxia
Meternal drugs
Infections
Meningitis
Pneumonia
Septicemia
Tachypnoea
Hypoxia
Metabolic and respiratory
acidosis
CNS hemorrhage
Hyaline membrane disease
Pulmonary edema
Aspiration
Maternal drugs: alcohol ,Mg,
Narcotics, barbiturates

134. Muscle Tone
Asphyxia
Maternal drugs
CNS damage
Myasthenia Gravis

135. Reflex Irritability
Hypoxia
Acidosis
Maternal drugs
CNS Injury
Congenital muscle disease

136. Color
Blue tinged at birth
60 sec. :pink
90 sec. : if central
cyanosis
Asphyxia
Low cardiac output
Pulmonary edema
Methemoglobinemia
Pulmonary disorders
Lung Hypoplasia
Diapharagamatic hernia
Airway obstruction
Respiratory distress
If pale
Asphyxia
Hypovolemia
Acidotic
Congenital heart disease
If rubrous
Polycythemia
If pink
Intoxicated with
Alcohol
Mg
Alkalotic pH>7.5

137. •Peripheral cyanosis (acro- cyanosis) is a normal phenomenon in a
newborn, but is given a score of one only. Totally pale (asphyxia
pallida) and centrally blue (Asphyxia livida) babies are given identical
scores, even though, the former is more grave.
•Muscle tone and reflex response are dependent on the gestational
age of the baby. Low birth weight preterm babies have feeble tone
and reflex and hence will have a low score
•The decision to start resuscitation is not based on Apgar score and
in fact , started earlier as soon as the baby is not breathing
•There is poor correlation between Apgar score and future neuro-
developmental outcome. However, if the Apgar score continues to be
low at 10 and 15 minutes after birth, the chances of cerebral palsy is
as high as 60%
Fallacies of Apgar Score

138. CPCR IN SPECIAL SITUATIONS

139. Cardiac Arrest Associated
With Asthma
BLS unchanged.
Ventilation strategy - low respiratory rate and tidal
volume – to dilute the effects of auto PEEP

140. adverse effect of auto-PEEP on coronary perfusion
pressure and capacity for successful defibrillation has
been
described in patients in cardiac arrest without asthma.51,52
Moreover,
the adverse effect of auto-PEEP on hemodynamics in
asthmatic patients who are not in cardiac arrest has also
been
well-described. since the effects of auto-PEEP in an
asthmatic patient with cardiac arrest are likely quite severe,
a ventilation strategy of low respiratory rate and tidal
volume is reasonable

141. During arrest a brief disconnection from the bag mask or
ventilator and compression of the chest wall to relieve air-
trapping can be effective
Tension pneumothorax should be considered and treated
For all asthmatic patients with cardiac arrest, and
especially for patients in whom ventilation is difficult, the
possible diagnosis of a tension pneumothorax should be
considered and treated

142. Cardiac Arrest Associated
With Anaphylaxis
Early and rapid advanced airway management is
critical and should not be unnecessarily delayed.
Intramuscular epinephrine
Recommended dose is 0.2 to 0.5 mg (1:1000) IM to
be repeated every 5 to 15 minutes in the absence
of clinical improvement

143. Drowning
Most detrimental consequence - hypoxia; therefore,
oxygenation, ventilation, and perfusion should be
restored as rapidly as possible
CPR for drowning victims should use the traditional
A-B-C approach in view of the hypoxic nature of the
arrest

144. Open the airway,
Check for breathing, and
 If there is no breathing, give 2 rescue breaths .
 Begin chest compressions and provide cycles of
compressions and ventilations according to
the BLS guidelines.
Attach an AED and attempt defibrillation if a
shockable rhythm is identified
If hypothermia – treat accordingly

145. Cardiac Arrest Associated With
Electric Shock and Lightning Strikes
Be sure of ones own safety
Initiate standard BLS resuscitation care
Maintain spinal stabilization if there is a
likelihood of head or neck trauma
Standard ACLS CARE
Early intubation for patients with
extensive burns

146. The primary cause of death in victims of lightning strike
is
cardiac arrest, which may be associated with primary VF
or
asystole. Lightning acts as an instantaneous, massive
direct-current shock, simultaneously depolarizing the
entire
myocardium. In many cases intrinsic cardiac
automaticity
may spontaneously restore organized cardiac activity
and a
perfusing rhythm. However, concomitant respiratory
arrest due
to thoracic muscle spasm and suppression of the
respiratory
center may continue after ROSC. Unless ventilation is
supported,

147. Cardiac Arrest Associated
With Trauma
Look for and correct reversible causes
of cardiac arrest
hypoxia
hypovolemia
diminished cardiac output secondary
to pneumothorax or pericardial
tamponade
hypothermia

148. BLS Modifications
Provide standard CPR and defibrillation
In multisystem trauma or head and neck trauma
Stabilize cervical spine
Airway by jaw thrust
Avoid head tilt– chin lift
 If breathing is inadequate and the patient’s face is
bloody, ventilation should be provided with a barrier
device, a pocket mask, or a bag-mask device while
maintaining cervical spine stabilization.
Stop any visible hemorrhage using direct
compression and appropriate dressings.

149. ACLS Modifications trauma pts
If bag-mask ventilation is inadequate,
an advanced airway should be inserted
while maintaining cervical spine
stabilization.
Consider a cricothyrotomy.

150. Cardiac Arrest in
Accidental Hypothermia
If pt is in pre arrest
prevent further loss of heat and rewarm the victim
immediately.
Removing wet garments and insulate from further
environmental exposures
transport to a center where aggressive rewarming
is possible

151. mild hypothermia- passive rewarming
Moderate hypothermia- external warming
techniques
a. forced air
b. Surface warming devices.
severe hypothermia- core rewarming
a. Warmed IV or intraosseous (IO) fluids
and
b. Warm humidified oxygen.

152. If pt is in cardiac arrest
begin CPR without delay
remove wet garments and
protect the victim from additional
environmental exposure.
Rewarming attempted when
feasible

153. ACLS Modifications - hypothermia
Aggressive active core rewarming
techniques as the primary therapeutic
modality.
1. CPB
2. Warm water lavage of thoracic cavity
3. Extracorporeal blood warming with
partial bypass
 administration of a vasopressor during
cardiac arrest according to the standard
ACLS algorithm
After ROSC, patients should continue to be
warmed to a goal temperature of
approximately 32° to 34°C

154. Cardiac Arrest Caused by
Cardiac Tamponade
Emergency
pericardiocentesis
Thoracotomy

155. Cardiac Arrest Associated With
Pulmonary Embolism
Often presents as pulseless electric
activity
In patients with cardiac arrest due to
presumed or known PE, it is
reasonable to administer fibrinolytics

156. Commotio Cordis
VF triggered by a blow to the anterior chest
during a cardiac repolarization
Commonly seen in young persons who are
engaged in sports
Prompt recognition that a precordial blow
may cause VF is critical.
Rapid defibrillation is often life-saving

157. Cardiac Arrest Associated With
Life-Threatening Electrolyte Disturbances
Current BLS and ACLS should be used to manage
cardiac arrest associated with all electrolyte
disturbances.

158. ACLS Modifications in Management of Severe
Cardiotoxicity or Cardiac Arrest Due to Hyperkalemia
 Administer adjuvant IV therapy in addition to
standard ACLS
 Stabilize myocardial cell membrane: Calcium
chloride (10%): 5 to 10 mL (500 to 1000 mg) IV over 2
to 5 minutes or calcium gluconate (10%): 15 to 30 mL
IV over 2 to 5 minutes
 Shift potassium into cells: Sodium bicarbonate: 50
mEq IV over 5 minutes

159. ACLS Modifications in Management of Cardiac Arrest
and Severe Cardiotoxicity Due to Hypermagnesemia
Administration of calcium (calcium chloride [10%] 5 to
10 mL or calcium gluconate [10%] 15 to 30 mL IV over
2 to 5 minutes) may be considered

160. ACLS Modifications in Management of Cardiac Arrest
and Severe Cardiotoxicity Due to Hypomagnesemia
 For cardiotoxicity and cardiac arrest, IV magnesium
1 to 2 g of MgSO4 bolus IV push

161. THANK YOU