Paediatric and Neonatal Resus (as adults if >8yrs)
Epidemiology
Most arrests are due to hypoxia, hypotension, acidosis, underlying illness (as opposed to cardiac causes in adults);
usually relieved by correction of A+B
Most common dysrhtymias are severe bradycardia, asystole; VF 7-15%; ventricular arrhythmia more common if
cardiac disease, poisoning, low voltage electrocution; SVT may cause shock; survival to discharge more common in
children and adolescents, than infants and adults; 2% survival without severe neuro deficit
5-10% neonate require resus; 1% require intensive resus
Weight
Newborn: 3.5kg
BLS / ALS
1yr: 10kg
1-10yrs: (age + 4) x 2
>10yrs: age x 3
A: Turn on side if drowning; no finger sweep unless solid FB seen;
infant = neutral, child = sniff
B: look, listen, feel 10secs
Do 5x rescue breaths (? Now 2) in children (not adult)
RR 10-12 (6-10 in adults) once ETT (every 15 compressions)
C: start CPR if unresponsive / not breathing properly
ALS provider can do pulse check
Use brachial / femoral pulse if <1yr
Start CPR if <60bpm with poor perfusion (absent in adults)
Pauses should be <10secs; Swap providers Q2min; Depth 1/3
AP diameter; finger <1yr, 1 or 2 hands thereafter; lower ½
sternum (<1yr go 1 finger below internipple line); 100/min
(100-120 in children); duty cycle 50%; 5 cycles / 2mins
3:1 in neonate; 15:2 in children; 30:2 in adult / 1
health care provider
Paddle size: 4.5cm infant, 8cm child; All shocks 4J/kg; High dose adrenaline not recommended
Rhythm check every 2mins (only check pulse if perfusable rhythm)
Help 1st as likely cardiac if: witnessed collapse or known cardiac condition in child
(and in all adults)
BLS 1st as likely respiratory: unwitnessed arrest in child (not in adults)  get help after 1min CPR
Continue until: breathes normally / impossible to continue / >20mins / no response to 2 doses adrenaline
/ core T 30deg with hypothermia
A
B
Neutral position if infant, sniffing for children; measure guedel from centre of mouth to angle of mandible
Use continuous ETCO2 monitoring; limit intubation attemps to 30secs as can go blue fast; press on larynx not cricoid,
but avoid submental digital pressure; aim to have audible leak as otherwise at risk of oedema; use Macintosh blade
once >6yrs; bradycardia common during ETT so consider atropine; jaw thrust may be superior to chin lift; NPA less
useful in children and may cause bleeding from adenoid tissue
BVM size: round mask 000-2 for infants / young child; shaped mask 3-5 for young child / adult
Bag size: 250ml in prem / 500ml in neonate or infant / 1500ml in child
ETT:
Mm: (age / 4) + 4 (uncuffed)
+ 3.5 (cuffed)
Decr size by 0.5mm if severe croup /
epiglottitis
Length: (age / 2) + 12 or 15
Weight
ETT width
ETT length
Crico tube
LMA
Larngoscope
RR
TV
PIP
PEEP
I:E
ICC (4x ETT)
<28/40
34-38/40
2.5mm
6.5-7cm
3.5mm
7-8cm
0 Miller
0 Miller
20ml/kg
>38/40
3.5kg
3.5-4mm
9cm
3.5mm
1
1 Miller
30-60
10ml/kg
15
3-5
1:2
8-12F
1yr
10kg
4mm
11cm
1.5-2
20-30
10ml/kg
3-5
1:2
14-20F
5yr
20kg
5mm
15cm
4mm
2-2.5
2 Miller
12-20
10ml/kg
20-25
3-5
1:2
20-28F
10yr .
30kg
.
6mm
16-17cm .
.
2.5-3
.
2 Mac .
10-12
10ml/kg
3-5
1:2
28-32F
Cuffed and uncuffed tubes equally safe, except in neonates; remember to place NGT
LMA: <5kg =1; 5-10kg = 1.5; 10-20kg = 2; 20-30kg = 2.5; 30-50kg = 3; 50-70kg = 4; 70-100kg = 5; >100kg = 6
Surgical: use cricothyroid puncture if <12yrs
Ventilator: have small air leak; NG mandatory; use p control ventilatory for infants
C
D
E
2Y survey
Post-resus
mng
BP = (age x 2) + 85
UO = 2ml/kg/hr in infant, 1ml/kg/hr in child
IVA: use IO if can’t get IVL in <90 secs if critically ill child
IO: insert in antmedial prox tibia 1 finger (2-3cm) beneath tibial tuberosity
sup to med malleolus
antlat distal femur 3cm above lateral condyle
Will not be able to aspirate from tibia if >5yrs due to fatty marrow; not reliable for PO2, PCO2, LFT; same onset of
drugs; can give up to 10-15ml/min; flush all drugs with 10ml N saline; CI = OP, osteogenesis imperfecta, #, recent
same bone IO, cellulitis, burns; complications rare (<1%; tibial #, growth retardation, compartment syndrome,
cellulitis, OM, extravasation of fluid)
Shock: 20ml/kg IVF  if still shocked after 40ml/kg, use inotropes / blood products
4ml/kg PRBC  incr Hb 1
10ml/kg plt  incr plt 50
Fluids: avoid 5% dex (worsens neuro outcome, causes 2Y diuresis; hypoNa)
Maintenance: use 0.45% saline + 2.5-5% dex in children
Use 0.18% saline + 10% dex in neonates
Shocks: unstable SVT: 0.5-1J/kg; pulsatile VT 0.5-2J/kg
Check: LOC, pupils, posture, glu
Beware T loss
Head to toe
B: aim SaO2 94-98% (PaO2 60-80mmHg); aim normocarbia
C: maintain adequate perfusion
D: therapeutic hypothermia (32-34) within 6hrs of cardiac arrest, and maintain up to 72hrs; avoid hypo/hyperG
Neonatal
resus
Epidemiology: required in 10% births; extensive resus in 1%; in >50% VLBW
Causes: iNborn errors of metabolism, Electrolytes, OD, Seizures, Enteric, Cardiac, Recipe (formula etc…), Endocrine,
Trauma, Sepsis
Cyanosis causes: airway obstruction (eg. Laryngeal web), congenital heart disease, pul disorders (eg. Aspiration,
pneumonia, diaphragmatic hernia), CNS (ICH), hypoG, sepsis/shock, metHb
Perinatal asphyxia: umbilical artery pH <7; 5min Apgar <4; neuro probs; MOF
Apgar score: `; if <7 at 5mins, continue Q5minly until >7; @ 1min, correlates with acidosis and survival; @5mins
correlates with neuro outcome; based on HR, resp effort, muscle tone, reflex irritability, colour
If >8, no resus needed
If 4-7  IPPV  intubate if no improvement at 30secs
If <4  intubate
Colour
HR
Reflex irritability
Tone
Respiration
0
Blue/pale
Absent
No response
Limp
Absent
1
Acrocyanotic
<100/min
Grimace
Some flexion
Weak cry / hypoV
2
Completely pink
>100/min
Cry / active withdrawal
Active motion
Good, crying
Fluid requirements in neonate: D1-2: 60-80ml/kg/day; D3-7: 100-150ml/kg/day; D 8-28: 120-180ml/kg/day
Meconium aspiration: staining occurs in 12-20%, but aspiration rare; 25-50% require mechanical ventilation; 5% die;
due to in utero fetal distress; if stained, suction as soon as head delivered
 do laryngoscopy and tracheal suction through ETT if: meconium staining + not vigorous (decr RR, decr tone, HR
<100); repeat until no further meconium withdrawn; if still severely depressed after meconium cleared, start
active resus
Stimulate, dry, warm (if prem,
may need plastic bag)
A: open airway, suction mouth
and nose; do Apgar after this
B: O2 if SaO2 <95%
Assess ventilation and HR:
IPPV via neopuff PEEP 5 if:
Apnoea for 30secs / gasping
HR <100
Persistent central cyanosis
despite 100% O2
Apgar 4-7
Use RR 30-40; give for 30secs; p
20mmHg (may need inflation p
30-35mmHg briefly, 20-25mmHg
in prems)
Assess HR again (after 30secs)
If HR >100  assess ventilation
If HR <100  further 30secs
ventilation
If HR <60 after 30secs ventilation
 commence CPR
Use 3:1; 1/3 depth of chest; lower
½ sternum, 100/min, will have RR
30
Assess again (after 30secs)
If not improving  ETT
Other Indications for ETT:
Prolonged resus / CPR
Prem
Meconium aspiration
Apgar <4
?congenital diaphragmatic hernia
VLBW
May need higher airway p and
PEEP in prems
For umbilical vein: insert catheter
10-12cm
Drugs
Adrenaline: 10mcg/kg IV/IO (= 0.1ml/kg 1:10,000)
100mcg/kg ETT (= 0.1ml/kg 1:1000)
Give after 2nd shock then every 2nd cycle
INF: 0.1-1mcg/kg/min
Amiodarone: 5mg/kg after 3rd shock  rpt dose after 5th shock  5-15mg/kg/min INF
Procainamide: 15mg/kg IV over 30-60mins
Atropine:
20mcg/kg (max 600mcg) IV  rpt at 5mins
Adenosine: 50-100mcg/kg  100mcg/kg  240mcg/kg (max 12mg)
Sux:
3mg/kg (neonate), 2mg/kg (child), 1.5mg/kg (adult)
Vec:
0.1mg/kg
Diazepam:
0.25mg/kg IV
Midaz:
0.15mg/kg IV
Dextrose:
5ml/kg 10% dex
HCO3:
Naloxone:
FB aspiration
Prognosis
1mmol/kg if pH <7.1; must have adequate ventilation
0.1mg/kg IM/IV (max 2mg) (give if maternal opiates <4hrs and resp depression after IPPV has
Restored normal HR and colour; CI if maternal narcotic addiction)
Calcium:
0.2ml/kg 10% CaCl, 0.6-1ml/kg 10% CaGlu; only if hyperK/Mg, hypoCa, Ca channel blocker OD
Effective cough: cough
Ineffective cough: unconscious  CPR, direct laryngoscopy ASAP
Conscious  5x back blows  5x chest thrusts (alternate with abdo thrusts in children)
Finger sweep if visible material
Outcomes from resus worse than in adults; 9% survival to discharge; if arrive to ED pulseless, death in 95%, all
survivors have poor neuro outcome
If CPR continued for 30mins with no ROSC, then continued resus is futile (may continue longer if arrest was
witnessed and CPR immediately)
Notes from: Dunn, Starship guidelines
Normal vital signs:
Age
Term
3/12
6/12
1yrs
2yrs
4yrs
5-6yrs
8yrs
10yrs
12yrs
14yrs
Weight
3.5kg
6kg
7.5kg
10kg
12kg
16kg
20kg
24kg
30kg
36kg
42kg
HR
110 – 170
30 – 40
100 – 160 20 – 30
80 – 130 20
70 – 115 15-20
70 – 110
60 – 100
BP = 85 + (age x 2)
Per kg
<10
10-20
>20
Neonatal:
Per day
100ml/kg
1000 +
50ml/kg
1500 +
20ml/kg
Per hour
4ml/kg
40 +
2ml/kg
60 +
1ml/kg
1-2d: 60-80ml/kg/day
3-7d: 100-150ml/kg/day
8-28d: 120-180ml/kg/day
tone tone
RR
40 – 60
30 – 50
SBP
50 - 90
60 - 90
65 - 90
70 – 100
75 – 110
80 – 110
85 – 120
90 – 120