PEDIATRIC ADVANCED LIFE

SUPPORT

Siloam Resuscitation Course - 2

 Cardiac Arrest Survival

 Since the start of using CPR in the 1980’s, in-hospital

survival for children and infants has increased from
9% to 27%
 Out-of-hospital arrests has not improved much from
6% for infants and 9% for children
 It is essential to teach more people who to treat cardiac
arrest in children, and give it as quickly as possible to
improve outcomes
 Difference in Cause

 Adults often have a primary cardiac cause for

cardiac arrest, but in children and infants, the
majority of the causes are due to respiratory failure
and shock
 Treat hypoxemia, hypotension, and acidosis to
prevent bradycardia and arrest!
 Ventricular fibrillation (VF) and ventricular
tachycardia (VT) are the primary causes of
arrhythmia arrests in children (5-15%)
 Age Definition

 Children
 Defined as 1 to 8 years old
 Infants
 Defined as < 1 year old
 Newborns
 Defined as first few hours to days of life
 Review of Basic CPR (SRC I)
2010 updated

 Check for responsiveness and respirations

 Call for help
 Check for pulses in less than 10 seconds
 Give 30 compressions (within 10 sec.)
 Rate of at least 100/min
 Depth of at least 1/3 of the chest
 Open airway and give 2 breaths
 Continue compressions (30:2)
 Review of Basic CPR (SRC I)
2010 updated

 Have AED available (with a pediatric dose-attenuator

if possible) for children
 For infants, a manual defibrillator is preferred,
although AED can be used if necessary
 2 to 4 J/kg initially, max of 10 J/kg
 Pediatric Assessment
 General Assessment
 Appearance, Work of breathing, Circulation
 Primary Assessment
 Airway, Breathing, Circulation, Disability, Exposure
 Secondary Assessment
 SAMPLE history, focused exam, glucose test
 Tertiary Assessment
 Laboratory studies, X-rays, etc as needed
 Pediatric Assessment

 Separate illness by respiratory versus circulatory

 Determine severity of illness
 Determine if there is a combination of illness
(respiratory and circulatory)
 If at any time there is respiratory failure or distress, or
circulatory shock, activate emergency response team!
 Possible Interventions
 Support ABC’s (CPR as needed)
 100% O2
 Assisted ventilation (bag mask or intubate)
 Cardiac or respiratory monitoring
 IV or IO (intraosseous) access
 Fluid resuscitation
 Laboratory studies (including glucose)
 Administer drugs or cardioversion
Size of Endotracheal Tubes
 Normal Vital Signs

Age Heart Rate Respiratory Systolic BP

Rate
< 1 year 85-180 30-40 70-90

1-2 100-150 25-35 80-95

2-5 60-140 25-30 80-100

5-12 60-120 20-25 90-110

 Fluids

 Used primarily for volume replacement and

medication delivery.
 Primarily Crystalloids in the Pre-hospital arena
 Large volumes may be needed, especially in septic
shock
 Crystalloids

 Normal Saline: Good for Fluid Boluses, compatible with

blood products, most drugs. 0.9% NaCl has an
osmolarity of 308 mOsm/liter, slightly greater than that
of plasma
 Lactated Ringers: Good for fluid boluses but is mildly
hypo-osmolar when compared to plasma
 D5W: Mainly for Hypoglycemia in the stable pt or for
infants.
 Dextrose containing solutions should not be used for
boluses
 IV access and Meds : Basic Facts
 In the critical pediatric Pt, Time to establish access
should be kept to a minimum.
 A General rule is “3 sticks in 90 seconds”
 Do not delay drugs to await IV access, give ET if
required.
 If traditional access is unlikely, proceed to alternative
means (intraosseous (IO) in the child under 6)
 Endotracheal (ET) Drugs

 Lipid soluble drugs can be given

 2-2.5 times standard IV dose (except for epinephrine)
 Should be diluted to a volume of 3-5 ml
 Should be hyperventilated after
 A use a 5 fr catheter to deliver the med depending on
size of ETT, then flush with 3-5 ml after
 Can give: NAVEL (narcan, atropine, valium,
epinephrine, lidocaine)
 Common PALS Drugs
Drips Resuscitation Drugs
 Epi
 Epi
 Atropine
 Dopamine
 Sodium Bicarb
 Lidocaine
 CaCl
 Narcan
 Lidocaine
 Amiodarone
 D50
 Adenocard
 Epinephrine
 Alpha and beta adrenergic effects
 2 standard concentration 1:1000 and 1:10,000
 Used in PALS in your unresponsive rhythms (asystole,
PEA, refractory bradycardia), anaphylaxis, asthma,
shock
 IV Dose 0.01 mg/kg of 1:10,000 q 3-5 min (max 1 mg)
 SQ or IM for asthma or anaphylaxis: 0.01 mg/kg 1:1000
q 15 min
 ETT 0.1 mg/kg of 1:1000 q 3-5 min
 Atropine
 Parasympatholytic
 May or may not be truly effective in small children in
arrest/asystole
 Good for vagus suppression during intubation
 0.02 mg/kg dose, maximum 0.5 mg
 Minimum dose (no matter weight) is 0.1 mg to avoid
refractory bradycardia
 Remember that most bradycardia in children are
hypoxic related
 Sodium Bicarbonate
 Used to treat metabolic acidosis during resuscitation
 Poor perfusion and ventilation are largest contributors
to acidosis
 Used after adequate ventilation has been restored
 0.1 mEq/kg IV/IO, repeated at 0.5 mEq/kg every 10
minutes
 Half strength is used for infants younger than 3
months
 Calcium
 Calcium is indicated in hypocalcaemia,
hypermagnesemia, and calcium channel blocker
overdose
 CaCl is considered more reliable and predictable in its
metabolization, thus it is used more often than Ca
gluconate in the critically ill
 Calcium gluconate dose and volume should be approx.
3 times that of CaCl
 1st dose should be 20 mg/kg (0.2 ml/kg) given slowly
 Narcan
 Narcotic antagonist
 Rapid onset, lasts about 30-45 minute
 < 5 years: 0.1 mg/kg
 >5 years of age: up to 2 mg (use adult dosing)
 Infusion: 0.004-0.16 mg/hour for total reversal
maintenance
 Should be used with caution in newborns from
addicted mothers as it may cause withdrawal seizures
 Lidocaine
 Anti-arrhythmic
 Indicated for VF/pulse less VT and post defibrillation
arrhythmic suppressant
 Used in Tachycardia algorithm for WIDE complex
Tachycardia
 Dose: 1 mg/kg max 3 mg/kg
 If successful, proceed to infusion
 D50
 Critically ill children (infants may rapidly deplete their
glycogen stores, especially during cardiopulmonary
distress)
 Glucose is especially important to the neonatal heart
 All pediatric patients in distress should have their BG
(blood glucose) checked
 Dose 1.0 gm/kg IV/IO, max concentration of 25%
(D25) used. A 10 % concentration may be advisable
for neonates (D10)
 Dopamine
 Vasopressor of choice for pre hospital use
 Dose dependant:
 2-5 mcg/kg/min increases renal blood flow
 5-10 mcg/kg/min causes beta adrenergic effects
 10-20 mcg/kg/min both alpha and beta effects
 Greater than 20 mcg/kg/min not routinely
recommended; mimics norepinephrine
 Used in shock without hypovolemia or after it has
been treated
 Amiodarone
 Antiarrhythmic (Class III) for SVT, VT, VF
 Dose: 5 mg/kg IV/IO load (bolus if unstable)
 May repeat as needed to max daily dose of 15 mg/kg
 Contraindicated in 2nd and 3rd degree AV block
 Specific Arrhythmia Algorithms
 In pediatrics they are divided into 3 main algorithms.
 First check if there is a pulse. If no pulse, go to PEA
 If there is a pulses, check rate. If slow go to bradycardia;
if fast, go to tachycardia

 PRACTICE, PRACTICE, PRACTICE! Mock drills are

essential to keep up your skills, so when you need them in
an emergency you are ready!
 There are constant advances in medicine, including
treatment of cardiac arrest. Keep up with the
literature and recommendations.
 As recommendations change, we will include them
in the material to reflect the latest information
available.
THANK YOU