90 CHAPTER 4: Cardiovascular Emergencies

Advanced Life Support

Successful treatment of cardiogenic shockinvolves minimizing the volume of fluid admin-istered and early consideration of a vasopressor.

Treatment of ObstructiveShock

The additional option for treatment of obstruc-tive shock from pneumothorax is needle tho-racostomy to decrease air tension as explainedin .

This technique will not remove blood, but willplace the pleural space at atmospheric pres-sure, and release air tension. Rapid transport isan essential feature of field management ofchest injury.

Initial Assessment:Transport Decision

After completing the initial assessment andbeginning general treatment when appropri-ate, the prehospital professional must decidewhether to go or stay on scene. If the PATand ABCDEs are normal and the child hasno history of serious illness or injury mech-anism, no anatomic abnormalities, and nopain, the child does not usually requireurgent treatment or immediate transport.Take the time to get a focused history andphysical exam and perform a detailed physi-cal examination (trauma) on the scene ifpossible.

On the other hand, if the child has aserious mechanism of injury, a physiologicor anatomic abnormality, severe pain, or ifthe scene is not safe, transport immediately.With such patients, do the additional assess-ment and attempt specific treatment on theway to the hospital, if possible.

The transport decision is sometimes dif-ficult in a child with a suspected cardiovas-

Needle Thoracostomy, Procedure 22

reverse the bronchospasm of anaphylaxis(beta effect). For all children with allergicreactions associated with wheezing, adminis-ter epinephrine, 0.01 mg/kg (0.01 mL/kg) of 1:1000 solution (maximum 0.3 mg or 0.3 mL) subcutaneously (SQ). If a child hashypoperfusion with anaphylaxis, administerepinephrine by IV, using a maximum dose of0.1 mg and a more dilute solution to decreasethe possibility of an adverse drug reaction.Draw up 0.01 mg/kg (0.1 mL/kg) of the1:10,000 epinephrine solution (maximum0.1 mg or 1 mL of the epinephrine) anddilute the solution further with 10 mL of nor-mal saline to reduce the epinephrine concen-tration to 1:100,000.

Treatment of CardiogenicShock

If cardiogenic shock is suspected by historyand/or physical assessment, transport aftergeneral noninvasive treatment. On the wayto the ED, consider vascular access. If thediagnosis of cardiogenic shock is uncertain,give a cautious fluid bolus of only 10 mL/kgof crystalloid fluid, and then reassessappearance, work of breathing, capillaryrefill time, heart rate, and blood pressure.

If there is no rhythm disturbance on thecardiac monitor, and the child remainspoorly perfused after the initial fluid bolus,consider a vasopressor agent, either dobuta-mine, dopamine, or epinephrine, if thetransport time is long. Start vasopressors atlow doses, based on per kilogram nomo-grams, and then titrate to achieve acceptableperfusion (improved appearance and skincirculation and decreased heart rate and res-piratory rate). If the child is known to be incongestive heart failure with cardiogenicshock, avoid fluid boluses and considervasopressor therapy as front-line treatmentif perfusion is severely compromised.

The major difference between treat-ment of hypovolemic, distributive, andcardiogenic shock is the amount of fluidadministration and consideration of avasopressor.

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