Pediatric Resuscitation
Your Worst Nightmare
Pediatric Cardiac Arrest
Usually secondary to respiratory failure or arrest
Most Important Intervention
Adequate oxygenation, ventilation
Basic Life Support
•Airway
–Head-tilt/chin-lift method
–Big tongue; Forward jaw displacement critical
–Avoid extreme hyperextension
–With possible neck injury, jaw thrust
Basic Life Support
•Breathing
–Look-Listen-Feel
–Limit to volume causing chest rise
–Children usually underventilated!
–Use BVM only if proficient
–Pedi BVM’s should not have pop-off valves
Basic Life Support
•Breathing
–Do NOT use demand valve on children
–Ventilate infants, children every 3 seconds
Basic Life Support
•Circulation
–Infants: brachial
–Children: carotid
Basic Life Support
•Circulation
–Infant chest compressions
•2 fingers
•1 finger width below nipple line
•1/2 - 1 inches
•At least 100/minute
•Consider circumferential compressions
–Two
Thumb Technique
Basic Life Support
•Circulation
–Child chest compressions
•One hand or two
•Lower half of sternum
•1 - 1.5 inches
•100/minute
Basic Life Support
•Circulation
–Child CPR
•Maintain continuous head tilt with hand on forehead
•Perform chin lift with other hand while ventilating
Best Sign of Effective Ventilation
Chest Rise
Best Sign of Effective Circulation
Pulse with Each Compression
Oxygen Therapy
•Initiate ASAP
•Do not delay BLS to obtain oxygen
Oxygen Therapy
•Use highest possible FiO2
–No risk in short term100% O2
•Humidify if possible
–Avoids plugging airways, adjuncts
Endotracheal Intubation
Need to intubate is not same as need to ventilate!
Endotracheal Intubation
•Proper tube size
–Same size as child’s little finger
–Child > 1 year: [(Age + 16 ) / 4]
Endotracheal Intubation
•Children < 8 years old
–Small tracheal diameter
–Narrow cricoid ring
–Uncuffed tubes
•Infants, small children
–Narrow, soft epiglottis
–Straight blade
Endotracheal Intubation
•Attempts not >30 seconds
•Bradycardia: oxygenate, ventilate
Endotracheal Intubation
•Avoid hyperextension
•Use “sniffing position”
•Lift up; do not pry back
Endotracheal Intubation
•Confirm placement by:
–Seeing tube go through cords
–Chest rise
–Equal breath sounds
–No sounds over epigastrium
–CO2 in exhaled air
Endotracheal Intubation
•Mark tube at corner of mouth
•Avoid excessive head movement
•Frequently reassess breath sounds
•Ventilate to cause gentle chest rise
Endotracheal Drugs
Epinephrine, atropine, lidocaine
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
Cricothyrotomy
•Surgical contraindicated in children <12
•Narrowing of trachea at cricoid ring makes procedure hazardous
•Use needle technique only
Vascular Access
•Same reasons as adults
–Drugs
–Fluids
Scalp Veins
•No value in cardiac arrest
•Useful in infants < 1 year old for maintenance fluids, drug route
Scalp Veins
•Rubber band for tourniquet
•21, 23 gauge butterfly
•Attach syringe, flush needle before inserting
Scalp Veins
•Point needle in direction of blood flow
•Leave syringe attached, inject 1cc saline after entering vein to check
infiltration
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
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
Prevention of Fluid Overload
•Avoid using bags over 250cc
•Use mini-drip sets, Volutrols
•Fluid resuscitation: 20cc/kg boluses
Intraosseous Cannulation
•Placement of cannula into long bone intramedullary canal (marrow
space)
Intraosseous Cannulation
•Indication
–Vascular access required
–Peripheral site cannot be obtained
•In two attempts, or
•After 90 seconds
Intraosseous Cannulation
•Devices
–16 gauge hypodermic needle
–Spinal needle with stylet
–Bone marrow needle (preferred)
Intraosseous Cannulation
•Site
–Anterior tibia
–1 - 3 cm below knee
–Medial to tibial tuberosity
Intraosseous Cannulation
•Contraindications
–Fractures
–Osteogenesis imperfecta
–Osteoporosis
–Failed attempt on same bone
Intraosseous Cannulation
•Needle in place if:
–Lack of resistance felt
–Needle stands without support
–Bone marrow aspirated
–Infusion flows freely
What can be put thru an IO?
Anything that can be put through an IV!
Defibrillation
•90% of pediatric cardiac arrest is
–Asystole, or
–Bradycardic PEA
•Defibrillation seldom needed
Defibrillation
•Pediatric VF suggests
–Electrolyte imbalances
–Drug toxicity
–Electrical injury
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
Defibrillation
•Energy Settings
–Initial: 2 J/kg
–Repeat: 4 J/kg
Cardioversion
•Cardiovert only if signs of decreased perfusion
•Energy settings:
–Initial: 0.5 - 1.0 J/kg
–Repeat: 2.0 J/kg
Cardioversion
•Narrow-complex tachycardia with rate < 200
–Usually sinus tachycardia
–Look for treatable underlying cause
–Do not cardiovert
Cardioversion
•Narrow-complex tachycardia with rate > 230
–Usually supraventricular tachycardia
–Frequently associated with congenital conduction abnormalities
Cardioversion
•Narrow-complex tachycardia with rate > 230
–If hemodynamically stable, transport
–Adenosine may be considered
•Dose = 0.1 mg / kg first dose (max 6 mg)
•2nd Dose = 0.2 mg / kg (max 12 mg)
Cardioversion
•Narrow-complex tachycardia with rate > 230
–If hemodynamically unstable, cardiovert
–If no conversion after two shocks, consider possibility rhythm is
sinus tachycardia
Drug Therapy
•Epinephrine
–Asystole, bradycardia PEA
–Stimulates electrical/mechanical activity
Drug Therapy
•Epinephrine Dosage
–IV or IO: 0.01 mg/kg 1:10,000
–ET: 0.1 mg/kg 1:1000
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
Drug Therapy
•Most bradycardias respond to
–Oxygen
–Ventilation
•For bradycardia 2o to hypoxia/ischemia, preferred first drug is
epinephrine
Drug Therapy
•For rare ventricular arrhythmias
–Amiodarone
•5 mg / kg
–Lidocaine
•1 - 1.5 mg / kg