Pediatric Resuscitation

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Pediatric Resuscitation
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Pediatric Cardiac Arrest

• Usually secondary to respiratory failure or
  arrest

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Most Important Intervention

• Adequate oxygenation, ventilation

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Basic Life Support

• Airway
• Head-tilt/chin-lift method
• Big tongue Forward jaw displacement critical
• Avoid extreme hyperextension
• With possible neck injury, jaw thrust

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Basic Life Support

• Breathing
• Look-Listen-Feel
• Limit to volume causing chest rise
• Children usually underventilated!
• Use BVM only if proficient
• Pedi BVMs should not have pop-off valves

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Basic Life Support

• Breathing
• Do NOT use demand valve on children
• Ventilate infants, children every 3 seconds

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Basic Life Support

• Circulation
• Infants brachial
• Children carotid

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Basic Life Support

• Circulation
• Infant chest compressions
• 2 fingers
• 1 finger width below nipple line
• 1/2 - 1 inches
• At least 100/minute

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Basic Life Support

• Circulation
• Child chest compressions
• One hand
• Lower half of sternum
• 1 - 1.5 inches
• 100/minute

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Basic Life Support

• Circulation
• Child CPR
• Maintain continuous head tilt with hand on
  forehead
• Perform chin lift with other hand while
  ventilating

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Best Sign of Effective Ventilation

• Chest Rise

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Best Sign of Effective Circulation

• Pulse with Each Compression

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Oxygen Therapy

• Initiate ASAP
• Do not delay BLS to obtain oxygen

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Oxygen Therapy

• Use highest possible FiO2
• No risk in short term100 O2
• Humidify if possible
• Avoids plugging airways, adjuncts

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Endotracheal Intubation

• Need to intubate is not same as need to
  ventilate!

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Endotracheal Intubation

• Proper tube size
• Same size as childs little finger
• Child gt 1 year (Age 16 ) / 4

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Endotracheal Intubation

• Children lt 8 years old
• Small tracheal diameter
• Narrow cricoid ring
• Uncuffed tubes
• Infants, small children
• Narrow, soft epiglottis
• Straight blade

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Endotracheal Intubation

• Attempts not gt30 seconds
• Bradycardia oxygenate, ventilate

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Endotracheal Intubation

• Avoid hyperextension
• Use sniffing position
• Lift up do not pry back

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Endotracheal Intubation

• Confirm placement by
• Seeing tube go through cords
• Chest rise
• Equal breath sounds
• No sounds over epigastrium
• CO2 in exhaled air

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Endotracheal Intubation

• Mark tube at corner of mouth
• Avoid excessive head movement
• Frequently reassess breath sounds
• Ventilate to cause gentle chest rise

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Endotracheal Drugs

• Epinephrine, atropine, lidocaine

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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

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Cricothyrotomy

• Surgical contraindicated in children lt12
• Narrowing of trachea at cricoid ring makes
  procedure hazardous
• Use needle technique only

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Vascular Access

• Same reasons as adults
• Drugs
• Fluids

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Scalp Veins

• No value in cardiac arrest
• Useful in infants lt 1 year old for maintenance
  fluids, drug route

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Scalp Veins

• Rubber band for tourniquet
• 21, 23 gauge butterfly
• Attach syringe, flush needle before inserting

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Scalp Veins

• Point needle in direction of blood flow
• Leave syringe attached, inject 1cc saline after
  entering vein to check infiltration

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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

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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

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Prevention of Fluid Overload

• Avoid using bags over 250cc
• Use mini-drip sets, Volutrols
• Fluid resuscitation 20cc/kg boluses

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Intraosseous Cannulation

• Placement of cannula into long bone
  intramedullary canal (marrow space)

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Intraosseous Cannulation

• Indication
• Vascular access required
• Peripheral site cannot be obtained
• In two attempts, or
• After 90 seconds

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Intraosseous Cannulation

• Devices
• 16 gauge hypodermic needle
• Spinal needle with stylet
• Bone marrow needle (preferred)

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Intraosseous Cannulation

• Site
• Anterior tibia
• 1 - 3 cm below knee
• Medial to tibial tuberosity

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Intraosseous Cannulation

• Contraindications
• Fractures
• Osteogenesis imperfecta
• Osteoporosis
• Failed attempt on same bone

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Intraosseous Cannulation

• Needle in place if
• Lack of resistance felt
• Needle stands without support
• Bone marrow aspirated
• Infusion flows freely

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What can be put thru an IO?

• Anything that can be put through an IV!

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Remember.

• You dont need a line to give drugs during a
  code.
• Epinephrine, atropine, lidocaine can go down tube

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Defibrillation

• 90 of pediatric cardiac arrest is
• Asystole, or
• Bradycardic PEA
• Defibrillation seldom needed

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Defibrillation

• Pediatric VF suggests
• Electrolyte imbalances
• Drug toxicity
• Electrical injury

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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

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Defibrillation

• Energy Settings
• Initial 2 J/kg
• Repeat 4 J/kg

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Cardioversion

• Cardiovert only if signs of decreased perfusion
• Energy settings
• Initial 0.5 - 1.0 J/kg
• Repeat 2.0 J/kg

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Cardioversion

• Narrow-complex tachycardia, rate lt 200
• Usually sinus tachycardia
• Look for treatable underlying cause
• Do not cardiovert

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Cardioversion

• Narrow-complex tachycardia, rate gt 230
• Usually supraventricular tachycardia
• Frequently associated with congenital conduction
  abnormalities

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Cardioversion

• Narrow-complex tachycardia, rate gt 230
• If hemodynamically stable, transport
• Adenosine may be considered

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Cardioversion

• Narrow-complex tachycardia, rate gt 230
• If hemodynamically unstable, cardiovert
• If no conversion after two shocks, consider
  possibility rhythm is sinus tachycardia

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Drug Therapy

• Epinephrine
• Asystole, bradycardia PEA
• Stimulates electrical/mechanical activity

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Drug Therapy

• Epinephrine Dosage
• IV or IO 0.01 mg/kg 110,000
• ET 0.1 mg/kg 11000

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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

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Drug Therapy

• Most bradycardias respond to
• Oxygen
• Ventilation
• For bradycardia 2o to hypoxia/ischemia, preferred
  first drug is epinephrine