Pediatric
Resuscitation
Ammar Al-Kashmiri
R5 Emergency Medicine
McGill University
Outline
Outcome and Chain of Survival
Recognition of a sick child
BLS
ALS
Challenges in Pediatric
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.
Outcome of cardiac arrest in
children
Arrive in ER in
cardiac arrest
(N = 80)
Admit PICU Died in ER
(N=43) 54 % (N=37) 46%
Mod Deficit PVS at Dead at Died in ICU
(N=3) 12 mos 12 mos (N=37) 46%
(N=2) (N=1)
Schindler M, et al. Outcome of out-of-hospital cardiac or
respiratory arrest in children. N Engl J Med 1996;335:1473-1479
Survival Rates in CPR
In-Hospital 10 %
Out of Hospital 10 - 34 %
Isolated Respiratory Arrest 95%
Pediatric Chain of Survival
Prevention CPR EMS ALS
Adult Chain of Survival
EMS CPR ALS
Early
Defibrillation
To Simplify
the Message…
Early
Defibrillatio
n
With exceptions… With exceptions…
(sudden collapse, cardiac history) (submersion, trauma, drug overdose)
Causes of Cardiac Arrest
SIDS AW obstruction
Trauma Severe Asthma
Submersion Pneumonia
Poisoning Metabolic Disorders
Sepsis Arrhythmias
Pediatric
Cardiorespiratory Arrests
10%
10% Respiratory
Shock
80%
Cardiac
Anticipating Cardiopulmonary
Arrest
Resp. Failure Shock
Rapid Cardiopulmonary
Assessment
A- Airway
B- Breathing
C- Circulation
Should take less than 30 seconds to
complete
Airway Assessment
Able to maintain independently
Requires adjuncts/assistance to maintain
Evaluation of Respiratory
Performance
Respiratory Rate Air Entry
Chest Expansion
Respiratory Mechanics Breath Sounds
Retractions, Accessory
Muscles use and Nasal
Color
Flaring
Head Bobbing
Grunting
Stridor
Wheezing
Cardiovascular Assessment
Heart rate CNS perfusion
BP Responsiveness (AVPU)
Vol./strength of Recognizes parents
central pulses Muscle tone
Peripheral pulses Pupil size
Present/absent Posturing
Volume/strength
Skin perfusion
Cap.refill time
Temperature
Color
Mottling
Basic Life Support
Airway Management
OBJECTIVE: Maintain Patent Airway
Open Airway
Head-tilt/chin-lift method
(big tongue, forward jaw displacement critical)
Jaw thrust method with possible neck injury
Suction
Artificial Airways
Oropharyngeal
Nasopharyngeal
Airway Management
Head Tilt-Chin Lift Jaw Thrust
Avoid extreme hyperextension
Breathing
Look-Listen-Feel
Breathing
Objective: Maintain Gas Exchange
Rescue Breathing
Mouth to mouth/nose-mouth
Bag and Mask
Self-inflating Bag-Mask
w/o reservoir 30 -80 % O2
with reservoir 60-95 % O2
Do NOT use demand valve
Breathing-How much and
how fast?
Adequate ventilation= adequate volume x adequate
rate
Volume: enough to cause chest rise
over 1-1.5 sec (esophageal
resistance may be overcome if
faster)
Rate: 20/min
synchronized w/ compressions at
a ratio of 1:5
Breathing- Adjuncts
Oropharyngeal Airway
PROPER
SIZE POSITION
Breathing- Adjuncts
Oropharyngeal Airway
IMPROPER POSITIONS
Breathing- Adjuncts
Nasopharyngeal Airway
Breathing
Bag-Mask Ventilation
Proper area for mask application
Breathing
Bag-Mask Ventilation
Breathing
Bag-Mask Ventilation
Sellick
Maneuver
Best Sign of Effective
Ventilation
Chest Rise
Circulation
Objective: Maintain adequate blood flow
to vital organs
How is this achieved by chest
compressions?
Circulation
Hemodynamics during CPR
Heart Compression or Thoracic Pump Model?
In children, direct cardiac compression is more
likely to be important secondary to the child’s
compliant chest.
compression should be directly over the heart
Circulation
In infants 1 finger breadth
below intermammary line
2 fingers or thumbs encircling
At least 100/minute
1/3 to 1/2 of chest
Brachial or femoral pulse is used to check for pulse
Circulation
In older children the lower
third of the sternum
Maintain continuous head tilt
with hand on forehead
One hand
100/minute
1/3 to 1/2 of chest
Carotid pulse is used to check for pulse
Circulation-Chest Compressions
Indications for chest compression:
Absent pulse
Heart rate 1 year:
ETT size:
(Age+16)/4
ETT depth (lip):
ETT size x 3
Tracheal Tube
Children 230
Usually supraventricular tachycardia
Rhythm is REGULAR
P waves may be difficult to see
QRS is narrow
Frequently associated with congenital
conduction abnormalities
If no conversion after two shocks, consider
possibility rhythm is sinus tachycardia
Supraventricular Tachycardia
Stable Adenosine 0.05 - 0.1 mg/Kg IV
Unstable Synchronized Cardioversion
SVT
Sinus Bradycardia
Rate: less than 60 BPM
Rhythm: regular
P waves: upright
QRS: following each P wave
Sinus Bradycardia
Most bradycardias respond to
Oxygen
Ventilation
For bradycardia 2o to hypoxia/ischemia,
preferred first drug is epinephrine
Bradycardia
*
*not an AHA recommendation!
;k
Update: 2000 AHA/ILCOR guidelines
VF
Rate: rapid, usually too disorganized to
count
Rhythm: irregular, wave forms vary in size
and shape
NO P waves, QRSs, ST segments,
or T waves discernable
Pulse: ABSENT
VF
Pediatric VF suggests
Electrolyte imbalances
Drug toxicity
Electrical injury
Ventricular Fibrillation/VT
Amio. 5mg/kg bolus IV/IO or Lido. 1 mg/kg
bolus IV/IO/PT or Mg 25-50 mg/kg IV/IO
for TDP or hypomag.
?
What is the rhythm?
VT
Rate: close to normal to more than 400
Rhyhm: usually regular
P waves: often not recognizable
QRS: wide
VT
Pulseless treat as VF
Pulse present
Stable Amiodarone 5mg/kg
Procainamide 15mg/kg
Lidocaine 1 mg/kg
Unstable Synchronized Cardioversion
Questions