Pediatric resuscitation
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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!


Pediatric assessment triangle

Pediatric Assessment Triangle


General appearance

General Appearance


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


Breathing evaluation

Breathing Evaluation


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 assessment

Cardiovascular Assessment


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 month60 mm Hg

>1 month to 1 year70 mm Hg

1 to 10 years of age70 mm Hg + (2  age in years)

>10 years of age90 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 Physiologic Status

  • Stable

  • Respiratory distress

  • Respiratory failure

  • Shock

    • Compensated

    • Decompensated

  • Cardiopulmonary failure


Rapid cardiopulmonary assessment summary

Rapid Cardiopulmonary Assessment: Summary

  • Evaluate general appearance

  • Assess ABCs

  • Classify physiologic status

    • Respiratory distress

    • Respiratory failure

    • Compensated shock

    • Decompensated shock

    • Cardiopulmonary failure

  • Begin management: support ABCs


Checkpoint

Checkpoint

  • 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

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?


What is this child s assessment

What is this Child’s Assessment?


Rapid cardiopulmonary assessment application1

Rapid Cardiopulmonary Assessment Application

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?


Rapid cardiopulmonary assessment application response to therapy

Rapid Cardiopulmonary Assessment Application: Response to Therapy

  • Vital signs improved


Pediatric intubation

Pediatric Intubation

Andrew Garrett, MD

Division of Transport and Emergency Medicine


Goals

Goals

  • 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

  • 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)

  • 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

epiglottis

True VC

False VC

cartilage

trachea

esophagus


Cricoid cartilage

Cricoid Cartilage


Airway anatomic differences intrathoracic

Airway Anatomic Differences(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?

  • The A of the ABC’s

    • Chin lift

    • Jaw thrust

    • Suction

    • Oropharyngeal airway

    • Nasopharyngeal airway


Intubation overview

Intubation Overview

  • Positioning

  • Choose the tube size

  • Choose the blade size and type

  • Insertion distance

  • Sedation

  • Paralysis

  • Equipment


Positioning the patient

Positioning the Patient

  • Alignment of the 3 axis

    • Oropharynx, Pharynx, Trachea

O

P

T


Positioning thoughts

Positioning thoughts

  • 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


Proper alignment for intubation almost

Proper alignment for intubation (almost…)


Tube size

Tube Size

  • 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

  • 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

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

  • Guidelines:

    • < 4 kgweight (kg) + 6 *

    • >4 kg3 x ET tube size

    • Distance to mandibular ridge

    • * usually a slightly high position


Confirmation of placement

Confirmation of Placement

  • Auscultation

  • Capnography

  • Radiography

  • Visualization


The technique of r s i

The Technique of R.S.I.

  • 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.

  • 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.

  • 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.

  • 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.

  • 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.

  • 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.

  • 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.

  • 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.

  • 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.

  • 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.

  • 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

  • “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

  • Fentanyl1-2 mcg/kg IV

  • Midazolam0.1 mg/kg IV

  • Diazepam0.1 mg/kg IV

  • Ketamine* 0.5-2 mg/kg IV

  • * can be tripled for IM dosing


Paralysis

Paralysis

  • Succinylcholine * 1-2 mg/kg IV

    • 5 to 10 min

  • Rocuronium1 mg/kg IV

    • ~30-45 minutes

  • Pancuronium0.1 mg/kg IV

    • ~1-2 hours

  • Vecuronium0.1 mg/kg IV

    • ~30 minutes

  • * can be doubled for IM dosing


Plans b and c

Plans B and C?

  • 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

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


The flow of things

The flow of things

  • 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:

  • 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?

Ideal circumstances!

Reality!


Circulation

Circulation

  • 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

  • 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

IV Fluids

Preload

Myocardial contractility

Afterload

Stroke volume

Heart rate

Cardiac output

Systemic vascularresistance


Cardiovascular cases

Cardiovascular Cases


Objectives

Objectives

  • 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

  • Shock is inadequate perfusion and oxygen delivery.

  • Hypotension is decreased systolic blood pressure.

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


Recognition of shock

Recognition of Shock


Management of shock

Management of Shock

Interventions:

  • Open airway

  • Provide supplemental oxygen

  • Support ventilation

  • Shock position

  • Vascular access/fluid resuscitation

  • Vasopressor support


9 month old infant

9-month-old infant

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


9 month old infant1

9-month-old infant

Appearance

Agitated, makes eye contact

Work of Breathing

No retractions or abnormal airway sounds

Circulation to Skin

Pale skin color


Initial assessment

Initial Assessment

  • 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


Pediatric resuscitation

What is this child’s physiologic state?

What are your treatment priorities?


Pediatric resuscitation

  • Assessment: Compensated shock, likely due to hypovolemia with viral illness

  • Treatment priorities:

    • Provide oxygen, as tolerated

    • Obtain IV access en route

      • Provide fluid resuscitation

        • 20 ml/kg of crystalloid, repeat as needed


Pediatric resuscitation

  • 160 ml normal saline infused

  • 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

  • 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

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

  • 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


Pediatric resuscitation

What is your assessment of this patient?

What is her problem?


Pediatric resuscitation

  • This patient is in decompensated shock.

    What are your treatment and transport priorities for this patient?


Treatment priorities

Treatment Priorities

  • 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


  • Pediatric resuscitation

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

    What are your treatment priorities now?


    Pediatric resuscitation

    • Consider endotracheal intubation

    • Provide second 20 ml/kg fluid bolus

    • Vasopressor support


    3 year old toddler

    3-year-old toddler

    • 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

    Appearance

    No spontaneous activity; unresponsive

    Work of Breathing

    Gurgling breath sounds

    Circulation to Skin

    Cyanotic, mottled


    Initial assessment2

    Initial Assessment

    • 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


    Pediatric resuscitation

    • The monitor shows the following rhythm.

      What are your treatment priorities for this patient?


    Treatment priorities1

    Treatment Priorities

    • 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


    Pediatric resuscitation

    • Patient’s heart rate improved to 70 beats/min with assisted ventilation.

    • Color, CRT and pulse quality improves.

    • After BVM, patient’s RR increases to 20 breaths/min, good chest rise

    • Rapid glucose check 100 mg/dL


    12 month old child

    12-month-old child

    • 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

    Work of Breathing

    Mild retractions

    Appearance

    Alert but agitated

    Circulation to Skin

    Lips and nailbeds blue


    Pediatric resuscitation

    • On initial assessment, you note clear breath sounds, a RR of 60 breaths/min and a heart rate that is too rapid to count.

      What rhythm does the monitor show?


    Pediatric resuscitation

    How can you distinguish SVT from sinus tachycardia?

    SVT

    Sinus Tachycardia


    Svt versus sinus tachycardia

    SVT versus Sinus Tachycardia


    Treatment priorities2

    Treatment Priorities

    • 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


    Pediatric resuscitation

    • Blow-by oxygen administered

    • 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

    • 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


    Two thumb encircling hands technique preferred

    Two Thumb–Encircling Hands Technique Preferred


    Effective bag mask ventilation is an essential bls skill

    Effective Bag-Mask Ventilation Is an Essential BLS Skill

    • 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

    • 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

    • 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 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 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

    • 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

    • 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

    • 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

    • 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 Causes 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 Causes of Arrest: 4 T’s

    • Tamponade

    • Tension pneumothorax

    • Toxins/poisons/drugs

    • Thromboembolism (pulmonary)


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