Pediatric Resuscitation

1. Pediatric Resuscitation

2. Pediatric Cardiac Arrest
Usually secondary to
respiratory failure or arrest

3. Most Important Intervention
Adequate
oxygenation, ventilation

4. Basic Life Support
nAirway
•Head-tilt/chin-lift method
•Big tongue; Forward jaw displacement critical
•Avoid extreme hyperextension
•With possible neck injury, jaw thrust

5. Basic Life Support
nBreathing
•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

6. Basic Life Support
nBreathing
•Do NOT use demand valve on children
•Ventilate infants, children every 3 seconds

7. Basic Life Support
nCirculation
•Infants: brachial
•Children: carotid

8. Basic Life Support
nCirculation
•Infant chest compressions
–2 fingers
–1 finger width below nipple line
–1/2 - 1 inches
–At least 100/minute

9. Basic Life Support
nCirculation
•Child chest compressions
–One hand
–Lower half of sternum
–1 - 1.5 inches
–100/minute

10. Basic Life Support
nCirculation
•Child CPR
–Maintain continuous head tilt with hand on
forehead
–Perform chin lift with other hand while
ventilating

11. Best Sign of Effective
Ventilation
Chest Rise

12. Best Sign of Effective
Circulation
Pulse with Each
Compression

13. Oxygen Therapy
nInitiate ASAP
nDo not delay BLS to obtain oxygen

14. Oxygen Therapy
nUse highest possible FiO
2
•No risk in short term100% O
2
nHumidify if possible
•Avoids plugging airways, adjuncts

15. Endotracheal Intubation
Need to intubate is not same as
need to ventilate!

16. Endotracheal Intubation
nProper tube size
•Same size as child’s little finger
•Child > 1 year: [(Age + 16 ) / 4]

17. Endotracheal Intubation
nChildren < 8 years old
•Small tracheal diameter
•Narrow cricoid ring
•Uncuffed tubes
nInfants, small children
•Narrow, soft epiglottis
•Straight blade

18. Endotracheal Intubation
nAttempts not >30 seconds
nBradycardia: oxygenate, ventilate

19. Endotracheal Intubation
nAvoid hyperextension
nUse “sniffing position”
nLift up; do not pry back

20. Endotracheal Intubation
nConfirm placement by:
•Seeing tube go through cords
•Chest rise
•Equal breath sounds
•No sounds over epigastrium
•CO
2
in exhaled air

21. Endotracheal Intubation
nMark tube at corner of mouth
nAvoid excessive head movement
nFrequently reassess breath sounds
nVentilate to cause gentle chest rise

22. Endotracheal Drugs
Epinephrine, atropine, lidocaine

23. Endotracheal Intubation
nDrug administration
•Do not delay while attempting IV access
•Dilute with normal saline
•Stop compressions
•Inject through catheter passed beyond ETT
•Follow 10 rapid ventilations

24. Cricothyrotomy
nSurgical contraindicated in children <12
nNarrowing of trachea at cricoid ring makes
procedure hazardous
nUse needle technique only

25. Vascular Access
nSame reasons as adults
•Drugs
•Fluids

26. Scalp Veins
nNo value in cardiac arrest
nUseful in infants < 1 year old for
maintenance fluids, drug route

27. Scalp Veins
nRubber band for tourniquet
n21, 23 gauge butterfly
nAttach syringe, flush needle before
inserting

28. Scalp Veins
nPoint needle in direction of blood flow
nLeave syringe attached, inject 1cc saline
after entering vein to check infiltration

29. Hand, Arm, Foot Veins
n22 gauge catheter for smaller children
nRestrain extremity before attempting
nIncise overlying skin with 19 gauge needle
nFlush needle as with scalp vein technique

30. External Jugular
nLife-threatening situations only
n22 gauge catheter
nRestrain by wrapping in sheet
nExtend head over end of table, rotate 90
0
nIf vein perforates, do not go to other side
•Risk of paratracheal hematoma, airway
obstruction

31. Prevention of Fluid Overload
nAvoid using bags over 250cc
nUse mini-drip sets, Volutrols
nFluid resuscitation: 20cc/kg boluses

32. Intraosseous Cannulation
nPlacement of cannula into long
bone intramedullary canal
(marrow space)

33. Intraosseous Cannulation
nIndication
•Vascular access required
•Peripheral site cannot be obtained
–In two attempts, or
–After 90 seconds

34. Intraosseous Cannulation
nDevices
•16 gauge hypodermic needle
•Spinal needle with stylet
•Bone marrow needle (preferred)

35. Intraosseous Cannulation
nSite
•Anterior tibia
•1 - 3 cm below knee
•Medial to tibial tuberosity

36. Intraosseous Cannulation
nContraindications
•Fractures
•Osteogenesis imperfecta
•Osteoporosis
•Failed attempt on same bone

37. Intraosseous Cannulation
nNeedle in place if:
•Lack of resistance felt
•Needle stands without support
•Bone marrow aspirated
•Infusion flows freely

38. What can be put thru an IO?
Anything that can be put through an IV!

39. Remember…….
nYou don’t need a line to give drugs during
a code.
nEpinephrine, atropine, lidocaine can go
down tube

40. Defibrillation
n90% of pediatric cardiac arrest is
•Asystole, or
•Bradycardic PEA
nDefibrillation seldom needed

41. Defibrillation
nPediatric VF suggests
•Electrolyte imbalances
•Drug toxicity
•Electrical injury

42. Defibrillation
nPaddle diameter:
•Infants: 4.5 cm
•Children: 8.0 cm
nLargest paddles that contact entire chest
wall without touching
nIf pediatric paddles unavailable, use adult
paddles with A-P placement

43. Defibrillation
nEnergy Settings
•Initial: 2 J/kg
•Repeat: 4 J/kg

44. Cardioversion
nCardiovert only if signs of decreased
perfusion
nEnergy settings:
•Initial: 0.5 - 1.0 J/kg
•Repeat: 2.0 J/kg

45. Cardioversion
nNarrow-complex tachycardia, rate < 200
•Usually sinus tachycardia
•Look for treatable underlying cause
•Do not cardiovert

46. Cardioversion
nNarrow-complex tachycardia, rate > 230
•Usually supraventricular tachycardia
•Frequently associated with congenital
conduction abnormalities

47. Cardioversion
nNarrow-complex tachycardia, rate > 230
•If hemodynamically stable, transport
•Adenosine may be considered

48. Cardioversion
nNarrow-complex tachycardia, rate > 230
•If hemodynamically unstable, cardiovert
•If no conversion after two shocks, consider
possibility rhythm is sinus tachycardia

49. Drug Therapy
nEpinephrine
•Asystole, bradycardia PEA
•Stimulates electrical/mechanical activity

50. Drug Therapy
nEpinephrine Dosage
•IV or IO: 0.01 mg/kg 1:10,000
•ET: 0.1 mg/kg 1:1000

51. Drug Therapy
nAtropine
•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

52. Drug Therapy
nMost bradycardias respond to
•Oxygen
•Ventilation
nFor bradycardia 2
o
to hypoxia/ischemia,
preferred first drug is epinephrine