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Abdul Chairy
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@abdul_chairy

Outline
Pediatric BLS + pediatric cardiac arrest
Primary assesment identify intervene

approach to a
acutely-ill child

Defibrillation
1st shock 2 J/kg,
Pediatric
subsequent shock 4 J/kg,
max. 10 J/kg orcardiac
adult dosearrest
Hypovolemia
Epinephrine
IO/IV 0.01
Hypoxia
mg/kg/dose
every
Hydrogen ion repeat
(acidosis)
Hypoglycemia
3-5 minutes or
Hypo-/hyperkalemia
0.1 mg/kg ET
Hypothermia
Tension pneumothorax
Tamponade, cardiac
Toxins
Thrombosis

Rationale for CAB vs ABC

Chest compression must be started right away to support
circulation & algorithms too complex needed
simplification (only 30% of children receive bystander
CPR)
Provision of ventilation delays the initiation of chest
compressions & thus circulation often by minutes
CPR was done poorly too slow too shallow & with
excessive ventilations which can impede cardiac output
Adults & children who suffer sudden cardiac arrest from Vfib/V-tach benefit from rapid CPR & defibrillation

Compression to ventilation
Health care provider if alone 30:2, otherwise
compression to ventilation rate 15:2
Push hard, push fast compress chest in infant 4 cm
and 5 cm in children allow chest to recoil compress
at least 100 x/min
Breathe 8-10 x/min avoid excessive ventilation
Switch rescuers every 2 minutes to avoid fatigue when
doing chest compression

Chest compressions

BMV vs ET Intubation
LOE 1 study shows no
difference in survival or
neurological outcome
Recommendation is that
BMV recommended over
ET intubation for
ventilatory support in outof-hospital settings

Minute ventilation
Avoid excessive ventilation of infants & children
during resuscitation from cardiac arrest; insufficient data
to identify optimal tidal volume or rate
Animal studies show excessive ventilation decreases
CPP, ROSC & survival
Excessive ventilation increases intrathoracic pressure
impedes venous return, reduces CO &
cerebral/coronary blood flow
During CPR ventilate 8-10 times per minute for infants
& children
TEKAN LEPAS LEPAS

Rapid Sequence Intubation

Allergy
Medications
Past history
Last meal
Events leading to
need for intubation

Obtain AMPLE &

examine patient
Prepare personnel, medication,
equipment
Monitor & pre-oxygenate
ECG, pulse oximeter

Pre-medicate
Give atropine 0.02 mg/kg (min 0.1 mg) iv
Indicated for all children <5 years of age
Indicated for all patients when succynilcholine is used
GIve lidocaine for head injury or increased ICP

Rapid Sequence Intubation (contd ..)

Sedate (choose one option based on condition of patient)

Normotensive
Midazolam 0.2 mg/kg
Etomidate
Thiopental
Propofol 1 mg/kg
Hypotensive/hypovolemic
Mild
Severe
Etomidate or Etomidate or
Ketamine or Ketamine or
Midazolam none

Head injury or status epilepticus

Normotensive
Hypotensive
Thiopental or
Etomidate or
Propofol or
Low-dose thiopental
Etomidate

Status asthmaticus
Midazolam or
Ketamine

Apply cricoid pressure

when patient is unconscious

Paralyze
Rocuronium
Vecuronium
Succinylcholine

Intubate trachea
Evaluate & confirm tube placement (eg. exhaled CO2)
Secure tracheal tube
Observe & monitor
Administer additional sedation & paralytics PRN
American Academy of Pediatrics /
American Heart Association

CUFFED VS UNCUFFED ETT

Cuffed tubes may be preferred in certain circumstances
poor lung compliance, high airway resistance, or large
glottic air leak, really any sick child (class IIa, LoE B)
Cuffed ETT will not cause pressure on the cricoid
cartilage leading to pressure necrosis (class IIa, LoE B)
Reintubation rate in uncuffed ETT is 30.8% vs 2.1% in
cuffed ETT
Uncuffed (age (yr)/4) + 4 = mmID
Cuffed (age (yr)/4) + 3.5 = mmID

Rapid Sequence Intubation

15

Troubleshooting
Displaced ET tube is not in trachea or has moved into a
bronchus (right mainstem most common)

Obstruction Consider secretions or kinking of the tube

Pneumothorax Consider chest trauma, barotrauma or
non-compliant lung disease

Equipment Check oxygen source, BVM and ventilator

The PAT

Circulation to Skin

Appearance
(TICLS)
Tone
Interactiveness
Consolability
Look/Gaze
Speech/Cry

Appearance
(AVPU)
Alert/Awake
Voice
Pain
Unresponsive

Appearance
Seizure?
Exposure? Burns, caustic
ingestion, CO, etc

Appearance
Seizure management
Diazepam rectal 5-10 mg or IV/IM 0.3-0.5 mg/kg
2-3 times
Phenytoin IV 15-20 mg/kg in 20 minutes
Phenytoin IV 10 mg/kg in 20 minutes
Phenobarbital IV 15-20 mg/kg
Phenobarbital IV 10 mg/kg

Work of Breathings

Abnormal airway sounds

Abnormal positioning
Abnormal respiratory rate
Retractions
Nasal flaring
SpO2

Work of Breathings

Upper airway obstruction

Lower airway obstruction
Lung tissue disease
Disorder control of
breathing

Upper Airway Obstruction

Lower Airway Obstruction

Intervention: Oxygen

Oxygen (contd ..)

Oxygen increasing evidence for harm limit
hyperoxemia start with 100% - later adjust to achieve
SpO2 >94%
The issues In reperfusion injury, hypoxic cells appear to
undergo metabolic changes that prime them to create free
radicals when oxygen is reintroduced
Experimental resuscitation with 100% oxygen has been
associated with a variety of concerning physiologic changes
when compared with room air resuscitation: increased
generation of oxygen radicals, decreased CNS sodiumpotasium ATPase function & decreased dopamine metabolism

27

Circulation to Skin

Circulation to Skin

Pallor
Mottling
Cyanosis
Capillary refill time

HYPOVOLEMI
C
SHOCK

DISTRIBUTIVE/SE
PTIC SHOCK

CARDIOGENI
C
SHOCK

MEDIATORS
Capilary
Leak

Myocardial
Depression
Vasodilatation
CONTRACTILITY

PRELOAD
CARDIAC OUTPUT

BLOOD PRESSURE

COMPENSATED
Sympathetic Discharge
Improved
Cardiac Output
and
Blood Pressure

Vasoconstriction
HR
Contractility

UNCOMPENSATE
D

Figure 3.1.
Sequence of pathophysiologic
events in clinical shock states.
From White MK, Hill JH, Blumer JL.
Shock in the pediatric patient. Act
Pediatr 1987:34:139-174

Myocardial Perfusion
Myocardial O2 Consumption

Myocardial Perfusion
MEDIATOR
RELEASE

TISSUE ISCHEMIA

Cell Function
Cell Death
DEATH OF ORGANISM

Loss of
autoregulator
of microcirculation

SHOCK
Typical signs of compensated
shock include
Tachycardia
Cool and pale distal extremities
Prolonged (>2 seconds)
capillary refill (despite warm
ambient temperature)
Weak peripheral pulses
compared with central pulses
Normal systolic blood pressure

As compensatory mechanisms fail,

signs of inadequate end-organ
perfusion develop. In addition to the
above, these signs include
Depressed mental status
Decreased urine output
Metabolic acidosis
Tachypnea
Weak central pulses
Deterioration in color (eg,
mottling, see below)

Circulation 2010;122;S876-S908

Initial management
0 min

Recognize decrease mental status & perfusion

Manage airway, breathing & IV/IO access

1 min

Initial resuscitation:
push boluses 20 cc/kg crystalloid or colloid up to 60 cc/kg
Correct hypoglycemia & hypocalcaemia. Begin antibiotics

15 min

Fluid refractory shock: Begin inotrope IV/IO

Reverse cold shock titrating dopamine up to 10 mcg/kg/min or, if
resistant, titrating central epinephrine 0.05-0,3 mcg/kg/min
Reverse warm shock titrating norepinephrine 0.5-3 mcg/kg/min

60 min

Catecholamine resistant shock

Lab work-up CBC, diff count, glucose (rapid), mixed venous GA,
blood culture, CRP/procalcitonin, ALT, SCr, PT/aPTT, electrolytes,
Brierley J et al. Crit Care Med 2009; 37:666-668
lactate, blood type

EGDT (early target)

1. Regain of consciousness
2. Normal peripheral pulse (malleolus media or dorsalis
pedis), warm acral, CRT <2
3. Normal BP & MAP & CVP (8-12 mmHg or 12-15 mmHg
if pt on MV)
4. Urine output > 1 ml/kg/hr
5. Broad-spectrum antibiotics (gram + & -)
6. ScvO2 >70%
7. Minimal Hb 7 (without shock) or 10 g/dL (shock or
hypoxemia)
Goldstein et al. Pediatr Crit Care Med 2005; 6(1):2-8

Intervention: Vascular access

Peripheral vein
Intraosseus

Often difficult to obtain in small &/or

acutely-ill child

Intraosseous
IO access is a rapid, safe, effective, and acceptable route
for vascular access in children.
All intravenous medications can be administered
intraosseously, including epinephrine, adenosine, fluids,
blood products and catecholamines.
Onset of action and drug levels for most drugs are
comparable to venous administration.
IO access can be used to obtain blood samples for analysis
including for type and cross match and blood gases during
CPR
Circulation 2010;122;S876-S908

Intraosseous infusion

Intraosseous infusion

Summary
Primary care physician should be able to detect
& manage emergency conditions in children
He/she should have the skill to perform CPR,
manage CABs which consist of BMV/RSI,
oxygen therapy, intraosseus infusion