Pediatric Recuscitation

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Introduction

Advanced Pediatric Life Support (APLS) focuses on assessment and management of ill or injured patients.

Pediatric Advanced Life Support (PALS) includes assessment and support of pulmonary and circulatory function before, during, and after arrest.

Neonate: first 28 days

Infant: birth-12 months

Child: 1-8 years

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Primary Survey

When first encountering a patient, initial assessment takes place within seconds. Observe level of consciousness, colour, rate and work of breathing, and obvious bleeding.

 

The primary survey begins with BLS, and an assessment of a patient's airway, breathing, and circulation. At each step, it is important to act before continuing. Shocks are provided according to montior and vital signs, not in in response to an AED's evaluation.

 

A secondary survey should be quickly done to identify possible causes of cardiac arrest (e.g., a heart attack, drug overdose, or trauma).

 

Throughout ACLS, it is critical to continue chest compression with minimal interruptions.

ACLS survey is often done by many team members, and should be on an ongoing basis throughout ACLS response.

 

In situations of sudden cardiac arrest, the approach recommended by the American Heart Association is C-A-B begin with chest compressions.

 

Airway

Is the airway open?

Does the patient need an advanced airway?

 

 

Breathing

Is oxygenation and ventilation sufficient?

If used, is the airway device properly placed and monitored?

Are CO2 and O2 sats being monitored?

 

 

Circulation

What is the current cardiac rhythm?

Is IV/IO access obtained?

Does the patient need fluids or medications?

 

 

Disability

 

 

Exposure

 

Differential Diagnosis

Why did arrest occur? Are there any other factors?

Can we reverse the cause(s)?

7 H's and 5 T's: pnemonic for mechanisms

  • hypoxia
  • hypovolemia
  • hyperkalemia
  • hypokalemia
  • hypoglycemia
  • hypothermia
  • hydrogen ions (acidosis)
  • tension pneumothorax
  • tamponade
  • toxins/therapeutics
  • thromboembolism (PE)
  • thrombus (myocardial infarction)
  • trauma

 

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Secondary Survey

Once the vital signs are identified and being addressed, proceed with a secondary survey.

A helpful acronym is SAMPLE:

 

 

Respiratory problems include:

 

Hypotension

Neonate: SBP <60mmHg

Infant: SBP <70mmHg

Child: SBP <70+ (2 x age)

>10 years: >90mmHg

 

What is the child's weight?

ECG is initially required to identify rhythm disturbance. Examine width of QRS complex, as well as presence or absence of P waves.

 

 

 

Clinical Scenarios

  • tachyarrhythmia
  • bradyarrhythmia
  • pulselessness

Tachyarrhythmia

A sinus tachycardia will normally be <220 bpm in an infant and <180 bpm in a child.

 

If tachycardia is sinus, treat the underlying condition. These include

  • hypoxia
  • hypovolemia
  • hyperthermia
  • fever
  • toxins
  • therapeutics
  • pain
  • anxiety

If supraventricular tachycardia is suspected, identify and treat possible causes. Consider vagal maneuvers (ice to the face in children), establish IV/IO access. Consider adenosine 0.1 mg/kg, max 6-12 mg. Use as rapidly as possible. Also options are amiodarone or procainamide.

 

Consider cardioversion with 0.5-1 J/kg.

 

If patient is unstable, or ventricular tachycardia is present, consider amiodarone 5mg/kg IV drip, or lidocaine 1 mg/kg.

Bradyarrthythmia

Bradycardias are often caused by hypoxia. Support airway and ventilation with oxygenation.

 

Begin chest compressions if HR is less than 60/min.

 

Consider epinephrine IV/IO at 0.01 mg/kg (0.1 ml/kg of 1:10,000 solution) or ET at 0.1 mg/kg.

 

If vagal stimulation or cholinergic poisoning is suspected, use atropine at 0.02 mg/kg (min = 0.1 mg, max = 0.5 mg in a child, 1 mg in an adolescent). Atropine may be given q5 minutes, to a total dose of 1 mg in a child (2 mg in an adolescent).

 

Cardiac pacing may be considered in bradycardia caused by congenital or acquired heart disease if there is third degree heart block.

 

Pulselessness

Defibrillation 2-4 J/kg

 

Epinephrine 0.01 mg/kg IV/IO every 3-5 minutes. High-dose epinephrine has had inconsistent evidence, but it appears outcomes may be worse.

 

Shock after 30-60 seconds of medication

Amiodarone 5mg/kg bolus IV/IO, or lidocaine 1 mg/kg IV/IO/TT bolus, or magnesium 25-50 mg/kg IV/IO for Torsades de pointes

 

 

Monitoring

Capnography can be used to assess effectiveness of CPR.

With ROSC

 

 

Critical Equipment

Broselow Tape allows for medication dosages, based on pediatric length to get weight.

Airways: NP airway: diameter less than that of nares. Measure from tip of nose to tragus.

IO

 

 

 

Resources and References

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