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Pediatric Resuscitation. Russian Field Hospital Nias, Indonesia 4/05. Lecture Objectives. The goal of this module: Perform rapid cardiopulmonary assessment Recognize signs of respiratory distress, respiratory failure, and shock. Progression of Respiratory Failure and Shock.

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Pediatric resuscitation

Pediatric Resuscitation

Russian Field Hospital

Nias, Indonesia

4/05


Lecture objectives
Lecture Objectives

The goal of this module:

  • Perform rapid cardiopulmonary assessment

  • Recognize signs of respiratory distress, respiratory failure, and shock


Progression of respiratory failure and shock
Progression of Respiratory Failure and Shock

Various Conditions

Respiratory failure

Shock

Cardiopulmonary failure

Cardiopulmonary arrest


Comparison of survival
Comparison of Survival

100%

Survivalrate

50%

0%

Respiratoryarrest

Cardiopulmonaryarrest


Rapid cardiopulmonary assessment
Rapid Cardiopulmonary Assessment

1. Evaluation of general appearance (mental status, tone, responsiveness)

2. Physical examination of airway, breathing, and circulation (ABCs)

3. Classification of physiologic status

Rapid cardiopulmonary assessment should be accomplished in less than 30 seconds!




Evaluation of general appearance
Evaluation of General Appearance

  • General color (“looks good” vs “looks bad”)

  • Mental status, responsiveness

  • Activity, movement,

    muscle tone

  • Age-appropriate response



Physical examination airway
Physical Examination: Airway

  • Clear

  • Maintainable

  • Not maintainable

    without intubation


Evaluating respirations
Evaluating Respirations

  • Respiratory rate

  • Respiratory effort (work of breathing)

  • Breath sounds/air entry/tidal volume

    • STRIDOR (inspiration)

    • WHEEZE (expiration)

  • Skin color and pulse oximetry


Rapid cardiopulmonary assessment classification of status
Rapid Cardiopulmonary Assessment:Classification of Status

  • Respiratory distress:Increased work of breathing

  • Respiratory failure:Inadequate oxygenation or ventilation



Cardiovascular variables affecting systemic perfusion

Blood pressure

Cardiovascular VariablesAffecting Systemic Perfusion

Preload

Myocardial contractility

Afterload

Stroke volume

Heart rate

Cardiac output

Systemic vascularresistance


Response to shock
Response to Shock

140

100

60

20

Vascular resistance

Percent of control

Blood pressure

Cardiacoutput

Compensated

shock

Decompensated

shock


Decompensated shock
Decompensated Shock

Compensatory mechanisms fail to maintain adequate cardiac output and blood pressure


Physical examination circulation
Physical Examination: Circulation

  • Cardiovascular function

    • Heart rate

    • Pulses, capillary refill

    • Blood pressure

  • End-organ function/perfusion

    • Brain

    • Skin

    • Kidneys


Physical examination circulation1
Physical Examination: Circulation

Typical Assessment Order:

  • Observe mental status

  • Feel for heart rate, pulse quality, skin temperature, capillary refill

  • Measure blood pressure

  • (Measure urine output later)


Physical examination circulation2
Physical Examination: Circulation

Evaluation of responsiveness

  • A — Awake

  • V — responsive toVoice

  • P — responsive toPain

  • U — Unresponsive


Heart rates in children
Heart Rates in Children

Infant

85 220 300

Normal

Compensating?

SVT

Child

60 180 200

Normal

Compensating?

SVT


Physical examination circulation3
Physical Examination: Circulation

Evaluation of skin perfusion

  • Temperature of extremities

  • Capillary refill

  • Color

    • Pink

    • Pale

    • Blue

    • Mottled


Palpation of central and distal pulses
Palpation of Central and Distal Pulses


Capillary refill
Capillary Refill

Prolonged capillary refill (10 seconds) in a

3-month-old with shock


Physical examination circulation4
Physical Examination:Circulation

Estimate of Minimum Systolic Blood Pressure

Age Minimum systolic blood pressure (5th percentile)

0 to 1 month 60 mm Hg

>1 month to 1 year 70 mm Hg

1 to 10 years of age 70 mm Hg + (2  age in years)

>10 years of age 90 mm Hg


Minimum systolic bp by age 5 of the range of normal
Minimum Systolic BP by age(5% of the range of normal)


Physical examination circulation5
Physical Examination:Circulation

  • Cardiovascular function

    • Heart rate

    • Pulses, capillary refill

    • Blood pressure

  • End-organ function/perfusion

    • Brain (Mental Status)

    • Skin (Capillary Refill Time)

    • Kidneys


Physical examination circulation6
Physical Examination: Circulation

Evaluation of End-Organ Perfusion

Kidneys

  • Urine Output

    • Normal: 1 to 2 mL/kg per hour

    • Initial measurement of urine in bladder not helpful


Classification of physiologic status shock
Classification of Physiologic Status: Shock

Early signs (compensated)

  • Increased heart rate

  • Poor systemic perfusion

    Late signs (decompensated)

  • Weak central pulses

  • Altered mental status

  • Hypotension


Septic shock is different
Septic Shock Is Different

  • Cardiac output may be variable

  • Perfusion may be high, normal, or low

  • Early signs of sepsis/septic shock include

    • Fever or hypothermia

    • Tachycardia and tachypnea

    • Leukocytosis, leukopenia, or increased bands


Special situations trauma
Special Situations: Trauma

  • Airway and Breathing problems are more common than Circulatory shock

  • Use the ABC or assessment triangle approach plus

    • Airway + cervical spine immobilization

    • Breathing + pneumothorax management

    • Circulation + control of bleeding

  • Identify and treat life-threatening injuries


Special situations trauma1
Special Situations: Trauma

Spinal Precautions?

Pneumothorax?

Bleeding control?


Special situations toxicology
Special Situations: Toxicology

  • Airway obstruction, Breathing depression, and Circulatory dysfunction may be present

  • Use the ABC and assessment triangle approach, plus watch for

    • Airway: reduced airway protective mechanisms

    • Breathing: respiratory depression

    • Circulation: arrhythmias, hypotension, coronary ischemia

  • Identify and treat reversible complications

  • Administer antidotes


Special situations toxicology1
Special Situations: Toxicology

Is the Patient Awake enough to maintain airway?

Respiratory Effort and Rate?

Arrythmias?

Vascular Tone?

Ischemia?


Classification of physiologic status cardiopulmonary failure
Classification of Physiologic Status: Cardiopulmonary Failure

Cardiopulmonary failure produces signs of

respiratory failure and shock:

  • Agonal respirations

  • Bradycardia

  • Cyanosis and poor perfusion


Classification of cardiopulmonary physiologic status
Classification of Cardiopulmonary FailurePhysiologic Status

  • Stable

  • Respiratory distress

  • Respiratory failure

  • Shock

    • Compensated

    • Decompensated

  • Cardiopulmonary failure


Rapid cardiopulmonary assessment summary
Rapid Cardiopulmonary Assessment: Summary Failure

  • Evaluate general appearance

  • Assess ABCs

  • Classify physiologic status

    • Respiratory distress

    • Respiratory failure

    • Compensated shock

    • Decompensated shock

    • Cardiopulmonary failure

  • Begin management: support ABCs


Checkpoint
Checkpoint Failure

  • Rapidly perform assessment

  • Use the information to prioritize your resuscitation efforts

  • Remember the Pediatric Assessment Triangle as we practice cases


Rapid cardiopulmonary assessment application
Rapid Cardiopulmonary Assessment Application Failure

A 3-week-old infant arrives in the ED:

  • CC: Severe vomiting and diarrhea

  • Physical exam: Gasping respirations, bradycardia, cyanosis, and poor perfusion

    What ar the results of your RAPID ASSESSMENT?

    What is the PHYSIOLOGIC STATUS?

    What are the emergency interventions?



Rapid cardiopulmonary assessment application1
Rapid Cardiopulmonary Assessment Application Failure

Case Progression

  • Response to intubation and ventilation with 100% oxygen:

    • Heart rate: 180 bpm

    • Blood pressure: 50 mm Hg systolic

    • Pink centrally, cyanotic peripherally

    • No peripheral pulses

    • No response to painful stimuli

      What is happening?

      What is next treatment step?



Pediatric intubation

Pediatric Intubation Therapy

Andrew Garrett, MD

Division of Transport and Emergency Medicine


Goals
Goals Therapy

  • Review of some basic concepts of pediatric airway management

  • Introduce/review RSI in a stress-free environment

  • Have a chance to practice intubation skills later today


Review and overview of airway management
Review and Overview of Airway Management Therapy

  • Children at higher risk for hypoxia and respiratory failure:

    • Anatomic differences

    • Higher metabolic rate

    • Ambiguous symptoms of hypoxia

    • Head trauma is common in pediatrics

    • Limited practice of management skills


Airway anatomic differences extrathoracic
Airway Anatomic Differences (Extrathoracic) Therapy

  • Relatively larger tongue

  • Tongue placed superiorly (C3-4)

  • Angle of epiglottis angled away from larynx

  • Vocal folds can trap ET tube

  • Narrowest area at cricoid vs. glottis


Anatomy
Anatomy Therapy

epiglottis

True VC

False VC

cartilage

trachea

esophagus



Airway anatomic differences intrathoracic
Airway Anatomic Differences Therapy(Intrathoracic)

  • Compliance of conducting airways at high flow rates

  • Fewer, smaller alveoli (< 8 yrs)

    • Smaller FRC (functional reserve)

    • Decreased diffusion

  • Metabolic Rate

    • 2 x adult oxygen consumption rate

    • Shorter tolerance of apnea


Can your patient be managed without intubation
Can your patient be managed without intubation? Therapy

  • The A of the ABC’s

    • Chin lift

    • Jaw thrust

    • Suction

    • Oropharyngeal airway

    • Nasopharyngeal airway


Intubation overview
Intubation Overview Therapy

  • Positioning

  • Choose the tube size

  • Choose the blade size and type

  • Insertion distance

  • Sedation

  • Paralysis

  • Equipment


Positioning the patient
Positioning the Patient Therapy

  • Alignment of the 3 axis

    • Oropharynx, Pharynx, Trachea

O

P

T


Positioning thoughts
Positioning thoughts Therapy

  • Don’t rush this part…

  • Be careful of cervical spine injury

  • Infant

    • Large occiput, gentle lift of shoulder

    • Use a folded towel

  • Adolescents and Adults

    • Extension of head on a towel support



Tube size
Tube Size Therapy

  • Cuffed vs. Uncuffed (age cutoff ~8 yrs)

    • Remember pediatric airway anatomy

  • ( Age + 4 ) / 4 for > 1 year old

  • 3.5 for newborn

  • 2.5 for preemie (< 28 weeks)

  • 3 for in between


Choose your blade
Choose your blade Therapy

  • Macintosh

    • Into the vallecula, lift the epiglottis from its foundation to visualize the trachea

  • Miller

    • Past the epiglottis, directly lift the epiglottis with traction to visualize


Macintosh vs miller
Macintosh vs. Miller Therapy

2

3

Preemie

Neonate

<2 yrs

2-6 yrs

6-12 yrs

>12 yrs

0

0

1

1.5

2

3


Insertion distance
Insertion Distance Therapy

  • Guidelines:

    • < 4 kg weight (kg) + 6 *

    • >4 kg 3 x ET tube size

    • Distance to mandibular ridge

    • * usually a slightly high position


Confirmation of placement
Confirmation of Placement Therapy

  • Auscultation

  • Capnography

  • Radiography

  • Visualization


The technique of r s i
The Technique of R.S.I. Therapy

  • Keep it simple, not stressful

  • In a nutshell:

    • What drug has been proven to increase the chance of successfully performing endotracheal intubation?


The technique of r s i1
The Technique of R.S.I. Therapy

  • Keep it simple, not stressful

  • In a nutshell:

    • What drug has been proven to increase the chance of successfully performing endotracheal intubation?

    • A paralytic agent such as succinylcholine


The technique of r s i2
The Technique of R.S.I. Therapy

  • Therefore, all RSI consists of is using a paralytic to increase the chance of being successful


The technique of r s i3
The Technique of R.S.I. Therapy

  • Therefore, all RSI consists of is using a paralytic to increase the chance of being successful

    • The rest of the drugs are because we’re nice (but that’s optional!)

      • SEDATIVE


The technique of r s i4
The Technique of R.S.I. Therapy

  • Therefore, all RSI consists of is using a paralytic to increase the chance of being successful

    • The rest of the drugs are because we’re nice (but that’s optional!)

      • SEDATIVE

        • Etomidate, benzos, propofol, etc.

        • Serves to make it a more pleasant experience

        • Don’t need to duplicate efforts


The technique of r s i5
The Technique of R.S.I. Therapy

  • Therefore, all RSI consists of is using a paralytic to increase the chance of being successful

    • Or because we think they should help prevent a side effect


The technique of r s i6
The Technique of R.S.I. Therapy

  • Therefore, all RSI consists of is using a paralytic to increase the chance of being successful

    • Or because we think they should help prevent a side effect

      • ATROPINE


The technique of r s i7
The Technique of R.S.I. Therapy

  • Therefore, all RSI consists of is using a paralytic to increase the chance of being successful

    • Or because we think they should help prevent a side effect

      • ATROPINE

        • Dryer work environment

        • Heart rate stabilization


The technique of r s i8
The Technique of R.S.I. Therapy

  • Therefore, all RSI consists of is using a paralytic to increase the chance of being successful

    • Or because we think they should help prevent a side effect

      • LIDOCAINE *


The technique of r s i9
The Technique of R.S.I. Therapy

  • Therefore, all RSI consists of is using a paralytic to increase the chance of being successful

    • Or because we think they should help prevent a side effect

      • LIDOCAINE *

        • A bit questionable

        • May help prevent ICP increase


The technique of r s i10
The Technique of R.S.I. Therapy

  • Don’t forget the basics though:

    • BVM skills

    • Positioning

    • Preparedness

  • Don’t rush, RSI is not a rescue airway technique, use BVM until you are ready


Rsi rapid sequence intubation
RSI: Rapid Sequence Intubation Therapy

  • “full stomach rule” in urgent intubations

  • Preoxygenation 1-5 minutes with 100%

  • Utilize Sellick maneuver

  • Choreography of medications

  • Confidence of providers to adequately ventilate after medications are given.

  • Rule out airway compression from mass effect if paralysis is being considered.


Sedation
Sedation Therapy

  • Fentanyl 1-2 mcg/kg IV

  • Midazolam 0.1 mg/kg IV

  • Diazepam 0.1 mg/kg IV

  • Ketamine* 0.5-2 mg/kg IV

  • * can be tripled for IM dosing


Paralysis
Paralysis Therapy

  • Succinylcholine * 1-2 mg/kg IV

    • 5 to 10 min

  • Rocuronium 1 mg/kg IV

    • ~30-45 minutes

  • Pancuronium 0.1 mg/kg IV

    • ~1-2 hours

  • Vecuronium 0.1 mg/kg IV

    • ~30 minutes

  • * can be doubled for IM dosing


Plans b and c
Plans B and C? Therapy

  • After deciding to undertake RSI

    • Make sure you have a backup/failed airway plan

      • LMA

      • Combitube

      • Fiberoptic, Bougie, Digital

    • The final option

      • Surgical airway

        • Percutaneous or Open


Equipment and technique
Equipment and Technique Therapy

Take a moment to double check your equipment and medications before you start


The flow of things
The flow of things Therapy

  • Examination (esp. neuro status, etc.)

  • Equipment checklist

  • Preoxygenate

  • Sedate, Paralyze, Intubate, Secure

  • Confirm placement

  • Continuous evaluation of placement


Tips from the field
Tips from the Field: Therapy

  • Know the size and depth of the tube

  • Confirm placement with every move

  • Tape tape tape!

  • When in doubt, take it out and bag!

  • Don’t forget the CXR

  • Check your battery and bulb


Ready to intubate
Ready to Intubate? Therapy

Ideal circumstances!

Reality!


Circulation
Circulation Therapy

  • After the RAPID ASSESSMENT is done

  • After BREATHING interventions are started

  • Priorities

    • STOP major bleeding

    • Get IV access

      • IV, IO, umbilical vein

      • We will review techniques


Circulation1
Circulation Therapy

  • Priorities

    • IV Fluids

      • Preload, afterload

      • Saline 20 mL per kg

      • Give it fast

      • Repeat assessments and vital signs

      • Repeat if necessary

      • Consider blood?


Iv fluids

Blood pressure Therapy

IV Fluids

Preload

Myocardial contractility

Afterload

Stroke volume

Heart rate

Cardiac output

Systemic vascularresistance



Objectives
Objectives Therapy

  • Differentiate shock from hypotension

  • Distinguish compensated from decompensated shock

  • Outline appropriate shock management

  • Identify and manage selected pediatric dysrhythmias


Shock and hypotension
Shock and Hypotension Therapy

  • Shock is inadequate perfusion and oxygen delivery.

  • Hypotension is decreased systolic blood pressure.

  • Shock can occur with increased, decreased, or normal blood pressure.



Management of shock
Management of Shock Therapy

Interventions:

  • Open airway

  • Provide supplemental oxygen

  • Support ventilation

  • Shock position

  • Vascular access/fluid resuscitation

  • Vasopressor support


9 month old infant
9-month-old infant Therapy

  • A 9-month-old presents with 3 days of vomiting, diarrhea and poor oral intake.


9 month old infant1
9-month-old infant Therapy

Appearance

Agitated, makes eye contact

Work of Breathing

No retractions or abnormal airway sounds

Circulation to Skin

Pale skin color


Initial assessment
Initial Assessment Therapy

  • Airway - Open and maintainable

  • Breathing - RR 50 breaths/min, clear lungs, good chest rise

  • Circulation - HR 180 beats/min; cool, dry, pale skin; CRT 3 seconds

  • Disability - AVPU=A

  • Exposure - No sign of trauma, weight 8 kg


What is this child’s physiologic state? Therapy

What are your treatment priorities?



  • 160 ml normal saline infused with viral illness

  • HR decreased to 140 beats/min

  • Patient alert and interactive, receiving second bolus on emergency department arrival


15 month old child
15-month-old child with viral illness

  • A previously healthy 15-month-old child presents with 12 hours of fever, 1 hour of lethargy and a “purple” rash.


15 month old child1
15-month-old child with viral illness

Appearance

No eye contact, lies still with no spontaneous movement

Work of Breathing

No retractions or abnormal airway sounds

Circulation to Skin

Pale skin color


Initial assessment1
Initial Assessment with viral illness

  • Airway - Open

  • Breathing - RR 60 breaths/min, poor chest rise

  • Circulation - HR 70 beats/min; faint brachial pulse; warm skin; CRT 4 seconds; BP 50 mm Hg/palp

  • Disability - AVPU=P

  • Exposure - Purple rash, no sign of trauma, weight 10 kg


What is your assessment of this patient? with viral illness

What is her problem?



Treatment priorities
Treatment Priorities with viral illness

  • Begin BVM ventilation with 100% oxygen.

  • Fluid resuscitation:

    • IV/IO access on scene

    • 20 ml/kg of crystalloid, repeat as needed en route

  • Vasopressor therapy


  • Patient received 20 ml/kg (200 ml) with no change in level of consciousness, HR or BP.

    What are your treatment priorities now?



    3 year old toddler
    3-year-old toddler of consciousness, HR or BP

    • Toddler is found cyanotic and unresponsive

    • Child last seen 1 hour prior to discovery

    • Open bottle of blood pressure medicine found next to child


    3 year old toddler1
    3-year-old toddler of consciousness, HR or BP

    Appearance

    No spontaneous activity; unresponsive

    Work of Breathing

    Gurgling breath sounds

    Circulation to Skin

    Cyanotic, mottled


    Initial assessment2
    Initial Assessment of consciousness, HR or BP

    • Airway - Partial obstruction by tongue

    • Breathing - RR 15 breaths/min, poor air entry

    • Circulation - HR 30 beats/min; faint femoral pulse; CRT 3 seconds; BP 50/30 mm Hg

    • Disability - AVPU=P

    • Exposure - No sign of trauma



    Treatment priorities1
    Treatment Priorities of consciousness, HR or BP

    • Open airway

    • BVM ventilation/consider intubation

    • Chest compressions

    • IV/IO access on scene

      • Medications (epinephrine, atropine)

      • Possible antidote - naloxone

      • Fluid resuscitation

    • Check glucose

    • Rapid transport



    12 month old child
    12-month-old child assisted ventilation.

    • You arrive at the house of a 12-month-old child.

    • Mother states the child has a history of heart disease and has been fussy for the last 3 hours.

    • Mother states the child weighs 10 kg.


    12 month old child1
    12-month-old child assisted ventilation.

    Work of Breathing

    Mild retractions

    Appearance

    Alert but agitated

    Circulation to Skin

    Lips and nailbeds blue



    How can you distinguish SVT from sinus tachycardia? 60 breaths/min and a heart rate that is too rapid to count.

    SVT

    Sinus Tachycardia


    Svt versus sinus tachycardia
    SVT versus Sinus Tachycardia 60 breaths/min and a heart rate that is too rapid to count.


    Treatment priorities2
    Treatment Priorities 60 breaths/min and a heart rate that is too rapid to count.

    • Supplemental oxygen

    • Obtain IV access

    • Convert rhythm based on hemodynamic stability

      • Stable: vagal maneuvers or adenosine

      • Unstable:

        • IV /IO access obtained - adenosine

        • No IV/IO and unconscious - synchronized cardioversion


    • Blow-by oxygen administered 60 breaths/min and a heart rate that is too rapid to count.

    • IV started

    • Adenosine 0.1 mg/kg (1mg), given rapid IVP with 5 ml saline flush

    • Five seconds of asystole, followed by conversion to NSR


    Conclusion
    Conclusion 60 breaths/min and a heart rate that is too rapid to count.

    • Cardiovascular compromise in children is often related to respiratory failure, hypovolemia, poisoning or sepsis.

    • Management priorities for shock include airway management, oxygen and fluid resuscitation.

    • Treat rhythm disturbances emergently only if signs of respiratory failure or shock are present.


    Advanced topics
    Advanced Topics 60 breaths/min and a heart rate that is too rapid to count.


    Two thumb encircling hands technique preferred
    Two Thumb–Encircling Hands Technique Preferred 60 breaths/min and a heart rate that is too rapid to count.


    Effective bag mask ventilation is an essential bls skill
    Effective Bag-Mask Ventilation Is an Essential BLS Skill 60 breaths/min and a heart rate that is too rapid to count.

    • Use only the amount of force and tidal volume needed to make the chest rise

    • Avoid excessive volume or pressure

    • Increased inspiratory time may reduce gastric inflation

    • Cricoid pressure may reduce gastric inflation

    Cricoid cartilage

    Occluded esophagus

    Cervical vertebrae


    2 rescuer bag mask ventilation
    2-Rescuer Bag-Mask Ventilation 60 breaths/min and a heart rate that is too rapid to count.

    • One rescuer uses both hands to open the airway and maintain a tight mask-to-face seal

    • The second rescuer compresses the manual resuscitator bag and may apply cricoid pressure if appropriate

    • Both rescuers verify adequate chest expansion


    Prehospital tracheal intubation vs bag mask ventilation
    Prehospital Tracheal Intubation vs Bag-Mask Ventilation 60 breaths/min and a heart rate that is too rapid to count.

    • Bag-mask ventilation may be as effective as intubation if transport time is short

    • Tracheal intubation requires training and experience

    • Confirmation of tracheal tube position strongly recommended

    • Monitoring of quality improvement important


    Complications of prehospital tracheal intubation
    Complications of 60 breaths/min and a heart rate that is too rapid to count.Prehospital Tracheal Intubation

    • Successful tracheal intubation rate: 57%

    • Intubation attempts increased time at the scene by 2 to 3 minutes

    • Unrecognized tube displacement or misplacement: 8%

      • Esophageal intubation: 2%

      • Unrecognized extubation: 6%

      • Esophageal intubation or unrecognized extubation fatal (for 14 of 15 patients)

    Gausche. JAMA. 2000;283:783.


    Confirmation of tracheal tube placement in pediatric advanced life support
    Confirmation of Tracheal Tube Placement 60 breaths/min and a heart rate that is too rapid to count.in Pediatric Advanced Life Support

    • Visualize tube through cords

    • Assess breath sounds, chest rise bilaterally

    • Secondary confirmation:

      • Oxygenation (oximetry)

      • Exhaled CO2 (capnography)


    Tube confirmation
    Tube Confirmation 60 breaths/min and a heart rate that is too rapid to count.

    • No single confirmation device or examination technique is 100% reliable

    • Detection of exhaled CO2 is reliable in patients weighing >2 kg with a heart rate

    • Exhaled CO2can be helpful in cardiac arrest

    • Confirmation of tube position is particularly important after intubation and after any patient movement


    Insertion of the laryngeal mask airway in children
    Insertion of the Laryngeal Mask Airway in Children 60 breaths/min and a heart rate that is too rapid to count.

    • The LMA consists of a tube with a cuffed mask at the distal end.

    • The LMA is blindly introduced into the pharynx until resistance is met; the cuff is then inflated and ventilation assessed.


    Use of laryngeal mask airway in pediatric advanced life support
    Use of Laryngeal Mask Airway in Pediatric Advanced Life Support

    • Extensive experience with pediatric and adult patients in the operating room

    • An acceptable alternative to intubation of the unresponsive patient when the healthcare provider is trained

    • Contraindicated if gag reflex intact

    • Limited data outside the operating room (Class Indeterminate)


    Intraosseous needles are recommended for patients 6 years of age
    Intraosseous Needles Are Recommended for Patients >6 Years of Age

    • Successful use of intraosseous needles has been documented in older children and adolescents

    • Devices for adult use are commercially available

    • “No one should die because of lack of vascular access”


    Drug therapy for cardiac arrest
    Drug Therapy for Cardiac Arrest of Age

    • Epinephrine: the drug of choice

      • Initial IV/IO dose: 0.01 mg/kg (tracheal: 0.1 mg/kg)

      • Do not routinely use high-dose (1:1,000) epinephrine

      • Good at getting heart rates to return

      • Poor long term outcome


    Resuscitation of the newly born outside the delivery room
    Resuscitation of the Newly Born Outside the Delivery Room of Age

    • Priority: Establish effective ventilation

    • Provide chest compressions if heart rate is <60 bpm despite adequate ventilation with 100% oxygen for 30 seconds

    • If meconium is observed in amniotic fluid:

      • Deliver head and suction pharynx (all infants)

      • If infant is vigorous, no direct tracheal suctioning

      • If respirations are depressed or absent, poor tone, or HR <100 bpm, suction trachea directly


    Potentially reversible causes of arrest 4 h s
    Potentially Reversible of AgeCauses of Arrest: 4 H’s

    • Hypoxemia

    • Hypovolemia

    • Hypothermia

    • Hyper-/hypokalemia and metabolic causes (eg, hypoglycemia)


    Potentially reversible causes of arrest 4 t s
    Potentially Reversible of AgeCauses of Arrest: 4 T’s

    • Tamponade

    • Tension pneumothorax

    • Toxins/poisons/drugs

    • Thromboembolism (pulmonary)


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