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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 pressureCardiovascular 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
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

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?

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?

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

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
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 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
  • 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
  • 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
  • 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?
  • 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 pressureIV Fluids

Preload

Myocardial contractility

Afterload

Stroke volume

Heart rate

Cardiac output

Systemic vascularresistance

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.
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
slide91
What is this child’s physiologic state?

What are your treatment priorities?

slide92
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
slide93
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
slide98
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
slide100
Patient received 20 ml/kg (200 ml) with no change in level of consciousness, HR or BP.

What are your treatment priorities now?

slide101
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
slide105
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
slide107
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

slide110
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?

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
slide114
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.
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)