Paediatric and Neonatal Resus
Epidemiology
Most arrests are due to hypoxia, hypotension, acidosis, underlying illness; usually relieved by correction of A+B
Most common dysrhythmias are severe bradycardia, asystole; VF 7-15%; ventricular arrhythmia more common if
cardiac disease, poisoning, low voltage electrocution; SVT may cause shock
5-10% neonate require resus; 1% require intensive resus
Weight
Newborn: 3.5kg
1yr: 10kg
1-10yrs: (age + 4) x 2
>10yrs: age x 3
BLS / ALS
A: Turn on side if drowning; no finger sweep unless solid FB seen;
infant = neutral, child = sniff
B: look, listen, feel 10secs
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; lower ½ sternum; 100-120/min (100 in
adults); duty cycle 50%; 5 cycles / 2mins
3:1 in neonate
15:2 in children (30:2 if layperson or 1 person)
30:2 in adult at all times
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)
Infant: 2 fingers
<8yrs: 1 hand
>8yrs: 2hands
Adult: 2 hands
Help 1st as likely cardiac if: witnessed collapse or known cardiac condition in child
(and in all adults)
st
BLS 1 as likely respiratory: unwitnessed arrest in child (not in adults)  get help after 1min CPR
Continue until: breathes normally / impossible to continue
A
B
Neutral position if infant, sniffing for children; measure guedel from centre of mouth to angle of mandible
Use continuous ETCO2 monitoring
BVM size: round mask 000-2 for infants / young child; shaped mask 3-5 for young child / adult
Bag size: 250ml bag in prem
500ml with pressure valve in neonate / infant
1500ml in young / older 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)
<28/40
Weight
ETT width
ETT length
LMA
Larngoscope
34-38/40
2.5mm
6.5-7cm
3.5mm
7-8cm
0 Miller
0 Miller
>38/40
3.5kg
3.5-4mm
9cm
1
1 Miller
1yr
10kg
4mm
11cm
1.5-2
5yr
20kg
5mm
15cm
2-2.5
2 Miller
10yr
30kg
6mm
16-17cm
2.5-3
2 Mac
.
.
.
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: RR 20-30 (infant), RR 12-20 (child); TV 7-10ml/kg; PIP 15 (neonate), 25 (RDS), 20-25 (child); PEEP 3-5; I:E
1:2; FiO2 100% initially; have small air leak; NG mandatory
IC catheter: neonate 8-12F
Infant 14-20F
Child 20-28F
Adolescent 28-36F
4x ETT size
Cricothyroidotomy cannula: adults 6mm, child 4mm, baby 3.5mm
C
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; can do Hb, but not
FBC; can do pH; same onset of drugs; can give up to 10-15ml/min (125ml/min under pressure); flush all drugs with
10ml N saline; CI = OP, osteogenesis imperfecta, #, recent same bone IO, cellulitis, burns; complications rare (<1%;
D
E
2Y survey
Post-resus
mng
Neonatal
resus
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 (32-34deg) within 6hrs of cardiac arrest, and maintain up to 72hrs;
avoid hypo/hyperG
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
Perinatal asphyxia: umbilical artery pH <7; 5min Apgar <4; neuro probs; MOF
Apgar score: measured at 1 and 5mins; if <7 at 5mins, continue Q5minly until >7
@1min, correlates with acidosis and survival; @5mins correlates with neuro outcome
0
1
2
.
Colour
Blue/pale
Acrocyanotic
Completely pink
HR
Absent
<100/min
>100/min
Reflex irritability
No response
Grimace
Cry / active withdrawal
Tone
Limp
Some flexion
Active motion
Respiration
Absent
Weak cry / hypoV
Good, crying
.
If >8, no resus needed
If 4-7  IPPV  intubate if no improvement at 30secs
If <4  intubate
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: 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%
Indications for IPPV via BVM:
Apnoea for 30secs / gasping
HR <100
Persistent central cyanosis
despite 100% O2
Apgar 4-7
Use RR 30-40; give for 30-60secs;
p 20mmHg (may need inflation p
30-35mmHg briefly, 20-25mmHg
in prems)
Indications for considering ETT:
Not improving after 30sec IPPV
Apgar <4
Prolonged resus (ie. Need for
chest compressions)
Prem
Meconium aspiration
?congenital diaphragmatic hernia
VLBW
May need higher airway p and
PEEP in prems
C:
Indications for chest
compressions
HR <60 after 30secs ventilatory
support
Use 3:1; 1/3 depth of chest; lower
½ sternum, 100/min, will have RR
30
For umbilical vein: insert catheter
10-12cm
Drugs
FB aspiration
Prognosis
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
Amiodarone: 5mg/kg after 3rd shock  rpt dose after 5th shock
Atropine:
0.02mg/kg (max 600mcg) IV
Adenosine: 50mcg/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:
2-5ml/kg 10% dex
HCO3:
1mmol/kg if pH <7.1
Naloxone:
0.1mg/kg IM/IV (give if maternal opiates <4hrs and resp depression after IPPV has restored normal HR
and colour; CI if maternal narcotic addiction)
Calcium:
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 (<10% intact survival rate); 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
RR
40 – 60
30 – 50
30 – 40
100 – 160 20 – 30
80 – 130 20
70 – 115 16
70 – 110
60 – 100
SBP
50 - 90
60 - 90
65 - 90
70 – 100
75 – 110
80 – 110
85 – 120
90 – 120
tone tone