JOE JONESNREMT-PARAMEDIC PEDIATRIC ADVANCED LIFE SUPPORT
PEDIATRIC CPR Establish Unresponsiveness: Open Airway Breathing: Look, Listen, Feel: Absent – Begin Ventilations, 2 breaths. Check pulse – Absent – Begin Compressions: 30 Compressions – 2 Ventilations, continue for 2 minutes or 5 cycles. Call for AED child > 1 year old/Cardiac Monitor check rhythm treat according to proper algorithm. Do not interrupt CPR for any extended period of time continue to compress and ventilate. Child age is considered to be from 1 – 8 y/o.
CPR CONTINUED When this is a single rescuer attempt, compression ratio is 30 -2 When there are two rescuers then deliver compressions at a rate of 15 – 2 This applies to infants and children. Note: When patient is intubated one should deliver ventilations 12 – 20 times/minute or one every 6 – 8 seconds.
PEDIATRIC ADVANCED LIFE SUPPORT CARDIAC ARREST SCENARIO You arrive to find a 5 year old male in your trauma room who was brought in by the mother stating he has not been acting right for the past 3 days. She GIVES YOU A HX OF ASTHMA AND PREMATURE BIRTH. THE CHILD IS NOTED TO BE WHAT APPEARS TO BE UNDER WEIGHT FOR HIS AGE. Mother states she has not been able to get him in to see M.D. due to the lack in her arms, there is no signs of trauma, you must act quickly..
Pediatric rhythm disturbances Airway: open Breathing: absent Circulation: absent What do we do now? Begin CPR 30 compressions to 2 ventilations Call for the monitor, doctor and all other appropriate personnel. When Monitor/AED arrive at bed side, connect, check rhythm and treat according to the PALS recommendations.
VENTRICULAR FIBRILLATIONPULSELESS VENTRICULAR TACHYCARDIA Monitor Attached, CPR stopped, MONITOR REVEAL RHYTHM ABOVE DEFIBRILLATE AT 2 JOULES PER KG. CONT. CPR 30 – 2 IV/IO IN PLACE BEGIN MEDICATIONS. EPINEPHRINE .01 ML. KG 1-10,000 CPR is Continued for two minutes and: DEFIBRILLATE: 4 JOULES PER KG. CONTINUE CPR AMIODARONE 5 MG. KG. LIDOCAINE 0.5 – 1 MG/KG MOST SKILLED PERSON INTUBATE THE TRACHEA, CONFIRM PLACEMENT USING END TITAL CO2, BBS, GOOD RISE-FALL CHEST, COMPLETE CPR, CONFIRM RHYTHM THEN: COMPLETE CPR CYCLE AND DEFIBRILLATE 4 JOULES KG. EPINEPHRINE .01MG KG REPEAT 3 – 5 MINUTES CORDARONE 5 MG. KG. or LIDOCAINE repeated max 3 mg. kg. Note: If Torsades is present, administer mag. Sulfate 25 – 50 mg. kg. epi .01 mg. kg. repeat 3 – 5 min.
ASYSTOLE/PEA CPR UNTIL MONITOR IS AVAILABLE THEN CONFIRM RHYTHM ABOVE CONTINUE CPR 30 – 2 INITIATE IV/IO AND ADMINISTER EPINEPHRINE .01 MG KG: (NOTE) USE BROSELOW TAPE INTUBATE/CONFIRM PLACEMENT NOTE: ONCE CORRECT PLACEMENT OF THE TUBE IS VERIFIED, THEN ONE DOES NOT NEED TO STOP COMPRESSIONS EPINEPHRINE .01 MG/ KG REPEAT 3-5 MIN. AT .01MG KG ATROPINE ?????? WHY: ____ USE ONLY IF A CARDIAC EVENT IS SUSPECTED CONSIDER CAUSES TREAT APPROPRIATELY EXAMPLE: HYPOXIA, ACIDOSIS, HYPOVOLEMIA, ELECTROLYTE IMBALANCE.
UNSTABLE TACHYCARDIA Remember a child is not considered to be in supraventricular tachycardia until the rate is > 180 beats per minute, Infants greater than 220. Rule out causes prior to beginning cardiac treatment!! Primary A-B-C’s Support that Airway Administer Oxygen Serious signs and symptoms present Synchronize Cardiovert at .5 - 1 joule – kg. Synchronize Cardiovert at 2 joules – kg. Move to medications. (REFER TO STABLE TACHYCARDIA FOR CORRECT MEDS AND DOSING). Remember support the airway.
SVT STABLE Primary A-B-C’s Administer oxygen Vagal maneuvers – blow in closed straw, ice water to face IV – IO in place Adenosine .01 mg. – kg. not to exceed 6 mg. repeat 3 – 5 minutes Adenosine. 02 mg. – kg not to exceed 12 mg. Adenosine .02 mg. – kg. not to exceed 12 mg. After Adenosine it will be M.D. choice; follow orders. MAY CONSIDER BETA BLOCKER/CALCIUM CHANNEL BLOCKERS OR CARDIOVERSION.
VENTRICULAR TACHYCARDIASTABLE V – Tach Primary A-B-C’s Administer oxygen IV – IO in place Amiodarone 5 mg. - kg. repeat in 5 – 10 minutes Procainamide 15mg/kg IV over 30 – 60 minutes. Do not administer Amiodarone and Procainamide together. Lidocaine may be used when Amiodarone is not available Remember do not rely on memory for drug doses, rely on Broslow Tape
BRADYCARDIA Primary A-B-C’s Administer oxygen. Remember Bradycardia in children is usually caused by hypoxia, don’t delay the administration of this DRUG IV – IO in place Epinephrine drug of choice. Use broslow tape for correct dose, never rely on memory for correct dose of medications in peds. Atropine???????? Primary cause is __________________? If the provider believes the cause of the bradycardia is from a Vagal response then Atropine would be the first drug of choice after oxygen. Dose is .02 mg. – kg. never give less than .1mg. Be sure to administer the medication rapid IVP.
SHOCK The most common cause of shock in a child is hypovolemia. This can come from several causes. Nausea/Vomiting, Bleeding, etc. The treatment of choice is fluids. Shock is defined as Inadequate Tissue Perfusion and is deadly if not corrected. It may be identified as Compensated or Decompensated shock. The difference in these two terms are Decompensated is when the blood pressure falls. Remember in children when the blood pressure begins to fall it happens quick so don’t wait for this symptom to occur.
TREATMENT OF SHOCK CONTINUED Primary A-B-C’s Administer oxygen high flow IV – IO Prior to the IO one should make 3 peripheral attempts or 90 seconds IO placed 2 cm. below tibial tuberosity medical side of the leg. It is confirmed in correct place when fluids and medications flow freely without signs of local tissue swelling. Administer now 20 ml. – kg. then reassess patient. This may be repeated times 4 for a total of 80 – ml-kg. in severe cases.
Pediatric shock Continued!! Pump problems are treated according to rhythms. Slow heart, speed up. Fast hearts, slow down. Do not overload your patient. One may choose to use a Vasopressor drug in this case. Examples of these drugs are: Dopamine – Dobutamine – Norepinephrine, Epinephrine . Milrinone may be used in the case of CHF for it’s classified as an inotropic medication.
Pediatric shock CONTINUED Rely on the Broslow tape for correct doses never rely on memory. Hypovolemic shock, non-hemorrhagic shock should be treated with fluids 20 ml./kg. reassess total up to 4 boluses. Hemorrhagic shock initial with fluids then PRBC’s 10 ml./kg or whole blood 20 ml/kg. To prevent adverse reactions one should warm prior to administration of blood. Septic shock fluids then consider ordering vasopressor along with hydrocortisone. Normotensive patient: use dopamine Hypotensive patient: warm shock vasodilated begin norepinephrine. Hypotensive patient: cold shock vasoconstricted use epinephrine rather than norepinephrine.
RESPIRATORY SCENARIO • You arrive in your trauma area and find a young mother holding a 3 year-old child in her arms. The child is in, what appears to be, extreme distress. She gives you a history of cold like symptoms over the past 2 – 4 days and unable to get him any better. She also advises you that the child has been experiencing asthma since he was 18 months old. • Physical Exam: Conscious, pale and crying with ventilations of greater than 50 minute. There is noted wheezes to all lung fields. What should you do for this patient?
RESPIRATORY TREATMENT • AIRWAY, BREATHING, CIRULATION • OXYGEN • BETA AGONIST MEDICATION VIA NEBULIZER • IV • CHEST X-RAY • CONSIDER STEROIDS • ADMIT FOR DEFINITIVE TREATMENT