Paediatrics Resuscitation 2015

Basic life support in a child; Advance life support in a child; Neonatal resuscitation; Umbilical catheterization

1. Department Family Medicine Dora Nginza Hospital Kemi Dele-Ijagbulu, M . B.Ch .B Paediatrics Resuscitation

2. OUTLINE PAEDIATRIC RESUSCITATION Basic life support in a child Advance life support in a child Neonatal resuscitation Umbilical catheterization

3. PAEDIATRIC RESUSCITATION A. BASIC LIFE SUPPORT B. ADVANCE LIFE SUPPORT c. Neonatal resuscitation d. UMBILICAL VESSEL CATHERIRIZATION

4. Challenges in Paediatric Resuscitation? Children are NOT just little adults! Different anatomy, different physiology and different pathology. Varying equipment shapes and sizes with varying ages. Challenging vascular access Definitions A newborn is a child just after birth. A neonate is a child in the first 28 days of life. An infant is a child under 1 year. A child is between 1 year and puberty.

5. Paediatric Chain of Survival Prevention CPR EMS ALS integrated post–cardiac arrest care

6. BASIC LIFE SUPPORT

7. BASIC LIFE SUPPORT HAZARD: ensure safety of rescuer and victim HELLO: check for response (call name. Are you okay?) Responsive unresponsive HELP: if unresponsive, not breathing or only gasping, get AED/defibrillator Assess the need for CPR (BOX 1) if the victim is unresponsive and is not breathing (or only gasping), send someone to activate the emergency response system. If responsive with regular breathing, the victim does not need CPR, put in recovery position

8. CIRCULATION Check pulse within 10secs (brachial in an infant and carotid or femoral in a child). Pulse: 1 rescue breath every 3 seconds) No pulse: Start Chest Compressions

9. Compressions For infants: Compress the sternum with 2 fingers placed just below the intermammary line. The 2-thumb–encircling hands technique is recommended when CPR is provided by 2 rescuers (encircle the infant's chest with both hands; spread your fingers around the thorax, and place your thumbs together over the lower third of the sternum and forcefully compress the sternum with your thumb) For older child: compress the lower half of the sternum with the heel of 1 or 2 hands. Ensure high-quality CPR: chest compressions of appropriate rate and depth; complete chest recoil; minimize interruptions; avoid excessive ventilation

10. Ventilations Ventilations (box 4): after 30 compressions (15 compressions if 2 rescuers), open the airway with a head tilt–chin lift and give 2 breaths. Bag-mask ventilation can be provided effectively during 2-person CPR AIRWAY open the airway using a head tilt–chin lift manoeuvre for both injured and non-injured victims. If there is evidence of trauma that suggests spinal injury, use a jaw thrust without head tilt to open the airway. Because maintaining a patent airway and providing adequate ventilation is important in paediatric CPR, use a head tilt–chin lift manoeuvre if the jaw thrust does not open the airway. In spinal injury, plane of face parallel to spine board BREATHING: give 2 effective breaths after 15 compressions for 2 rescuers/ 30 compressions lone rescuer. (Effective breaths = the chest rises)

11. BASIC LIFE SUPPORT cont. ANALYSE RHYTHM: AED IN CHILDREN Shockable: 1 shock continue CPR Non-Shockable: continue CPR until patient becomes responsive or ALS providers take over Age > 8 years: use adult AED •Age 1-8 years: use paediatric pads/settings if available (otherwise use adult mode) •Age < 1 year: use only if manufacturer instructions indicate it is safe REASSES after 2min for pulses Present: post-resuscitation care Absent: continue CPR

12. Paediatric Advanced Life Support

13. Airway By now you should’ve established whether your patient is able to maintain his/her own airway Decide on the appropriate airway adjunct to provide adequate ventilation. Oropharyngeal and nasopharyngeal airways Oropharyngeal and nasopharyngeal airways help maintain an open airway by displacing the tongue or soft palate from the pharyngeal air passages. Oropharyngeal airways are used in unresponsive victims who do not have a gag reflex. Nasopharyngeal airways can be used in children who do have a gag reflex. Size determination Oropharyngeal airways: age/2 + 12 Nasopharyngeal airways age/2 + 15

14. Airway – cont. Oxygen: monitor systemic oxygen saturation. Titrate oxygen administration to maintain the oxyhemoglobin saturation ≥94%. Pulse oximetry: monitor oxyhemoglobin saturation continuously with a pulse oximeter . Pulse oximetry may, however, also be unreliable in patients with poor peripheral perfusion, carbon monoxide poisoning, or methemoglobinemia . Bag-mask ventilation: selecting a correct mask size, maintaining an open airway, providing a tight seal between mask and face, providing ventilation, and assessing effectiveness of ventilation Ventilation with an endotracheal tube Endotracheal tube size ETT size determination (Use uncuffed tubes) < 1yr: 3-3.5mm >1yr: age/4 + 4

15. ANATOMICAL Airway Differences ANATOMICAL Airway Differences Large head, short neck – airway narrowing Small jaw, loose teeth, big tongue – difficult intubation Horse shoe larynx – straight blade laryngoscope Cricoid cartilage with surrounding loose connective tissue – susceptible to oedema

16. Breathing Breathing – can patient maintain spontaneous ventilation or is measure necessary to provide adequate oxygen. Decide on the appropriate airway adjunct to provide adequate ventilation. Anatomical breathing differences Nose breathers and smaller airways – easily obstructed Horizontal ribs – reduced expansion Diaphragmatic breathing – fatigue causing respiratory failure

17. Circulation Observe for any signs of active haemorrhage. Assess for cardiac dysthymias. Vascular access: Vascular access – peripheral ivvenous access is essential for administering medications and drawing blood samples. Intraosseous (IO) access: IO access is a rapid, safe, effective, and acceptable route for vascular access in children, and it is useful as the initial vascular access in cases of cardiac arrest. All intravenous medications can be administered intraosseously, including epinephrine, adenosine, fluids, and blood products Circulation differences Blood volume (70-80ml/kg) Small blood volume loss is more significant than in adults

18. Drugs/Defibrillate Drugs/Defibrillate if indicated Adenosine Amiodarone Calcium Epinephrine Glucose Magnesium Procainamide Sodium bicarbonate Vasopressin Drug dosages and joules for shocking are different  BY NOW EITHER A SUCCESFUL RESUS HAS BEEN COMPLETED OR NOT

19. Neonatal resuscitation

20. Umbilical CATHERIZATION

21. Umbilical CATHERIZATION INDICATIONS Vein: Emergency IV access for the administration of fluid, drugs, or hypertonic glucose Monitoring CVP Venous blood sampling Exchange transfusions Central venous access in patients needing long term parenteral nutrition Artery Arterial blood sampling /Arterial blood pressure monitoring / Angiography Administration of fluids and drugs Exchange transfusions (removal of blood)

22. Umbilical CATHERIZATION – cont. Contraindications Peritonitis Necrotizing enterocolitis Omphalitis / omphalocele / gastroschisis Peritonitis UAC: evidence of local vascular compromise in lower limbs or buttocks UVC: portal venous hypertension

23. Umbilical CATHERIZATION – cont.

24. Technique 1. Place the infant beneath a radiant warmer and restrain the extremities. 2. Prepare the abdomen and umbilicus with antiseptic solution (surgical prep). 3. Drape the umbilical area in a sterile manner. Expose the infant’s head for observation. 4. To anchor the line after placement, place a constricting loop of umbilical tape at the base of the cord. Using a scalpel blade, trim the umbilical cord to 1 to 2 cm above the skin surface. 5. Identify the umbilical vessels. The umbilical vein is a single, thin-walled, large-diameter lumen, usually located at 12 o’clock. The arteries are paired and have thicker walls with a small-diameter lumen. 6. Obtain an umbilical vascular catheter (5 fr). Flush the catheter with heparinized saline (1 unit per ml) and attach it to a 3-way stopcock.

25. Technique – cont. 7. Measure and mark 5 cm from the tip of the catheter. 8. Close the ends of a pair of smooth forceps, then insert the end into the lumen of the umbilical vein. Dilate the opening by allowing the ends of the forceps to separate, then insert the catheter into the lumen of the umbilical vein and advance it gently toward the liver for 4 to 5 cm or until blood return is noted. 9. If resistance to advancement of the catheter is encountered, the tip might be in the portal vein or the ductus venosus . The catheter should be pulled back until blood can be withdrawn smoothly. 10. Remove the catheter when resuscitation is complete and peripheral vascular access has been obtained.

26. Thank you!