Cardiopumonary Arrest

P.A.L.SPediatric Advanced Life Support

Start CPR•Give oxygen

•Attach monitor/defibrillator

VF/VT Asystole /PEA

Yes No

Pediatric cardiac arrestShout for help, Activate emergency

response

rhythmShockable?

Asystole and Pulseless Electrical Activity

Asystole or Pulseless Electrical Activity

Asystole / Pulseless Electrical Activity

Resume CPR immediately for 2 min

IV/IO available: Epinephrin :0.01 mg/kg (0.1 mL/kg of 1:10 000 solution) Repeat every 3 to 5 min

No IV/IO: ETTEphinephrin: 0. 1 mg/kg (0.1 mL/kg of 1:1000 solution)of 1:1000 solution)

Consider advanced airway

7

Reversible Causes

6H5THypoxiaTension pneumothorax

HypovolaemiaTamponade

Hyper/hypokalaemiaToxins

HypothermiaThrombosis,coronary

HypoglycemiaThrombosis, pulmonary

Hydrogen ion (acidosis)

Start CPR•Give oxygen

•Attach monitor/defibrillator

VF/VT Asystole /PEA

Yes No

Pediatric cardiac arrestShout for help, Activate emergency

response

rhythmShockable?

Ventricular Fibrillation/Pulseless Ventricular Tachycardia

Ventricular Tachycardia

Rateusually between 100 to 220/bpm, but can be as rapid as 250/bpm

P waveobscured if present and are unrelated to the QRS complexes .

QRSwide and bizarre morphologyConductionas with pvc

Rhythmthree or more ventricular beats in a row; may be regular or irregular .

Ventricular Fibrillation

Ventricular Fibrillation

Rateunattainable

P wavemay be present, but obscured by ventricular waves

QRSnot apparent

Conductionchaotic electrical activity

Rhythmchaotic electrical activity

Defibrillators

• Defibrillators are either manual o automated (AED).

• AED can be used for infants and children up to approximately 25 kg (8 years of age).

• In infants 1 year of age a manual defibrillator is preferred.

Defibrillators

• Defibrillators are either manual o automated (AED).

• AED can be used for infants and children up to approximately 25 kg (8 years of age).

• In infants 1 year of age a manual defibrillator is preferred.

Defibrillators

• Defibrillators are either manual o automated (AED).

• AED can be used for infants and children up to approximately 25 kg (8 years of age).

• In infants 1 year of age a manual defibrillator is preferred.

Defibrillators

Paddle Size Two sizes of hand-held paddle

“Adult” size : 8 to 10 cm for children > 10 kg ( approximately 1 year)

“Infant” size :4-5 cm for infants < 10 kg

Defibrillators

Paddle Position: Place over the right side of the upper chest and the

apex of the heart (to the left of the nipple over the left lower ribs) so the heart is between the two paddles.

Apply firm pressure

Defibrillators

Interface:

• Gel pads, electrode cream or paste, or self-adhesive monitoring-defibrillation pads.

• Do not use saline-soaked pads, ultrasound gel, bare paddles, or alcohol pads.

Defibrillators

Energy Dose:

• Initial dose of 2 J/kg

• Increase the dose to 4 J/kg

• Higher energy levels may be considered, not to exceed 10 J/kg or the adult maximum dose.

Pediatric Arrhythmias

•Bradycardia•Tachycardia

Heart Rate

AgeHeart Rate (beats/min)Birth–4 wk130-190

1–3 mo125-1853–6 mo110-165

6–12 mo105-1951–3 y100-1553–5 y70-1205–8 y60-110

8–12 y55-10012–16 y50-100

Bradycardia

• Emergency treatment of bradycardia is indicated when the rhythm results in hemodynamic compromise:

• Hypotension

• Acutely altered mental status

• Signs of shock

Atropine

• 0.02 mg/kg IV/IO (Repeat once if needed)– Minimum dose: 0.1 mg– Max single dose: 0.5 mg

Bradycardia

• Pacing is not useful for asystole or bradycardia due to postarrest hypoxic/ ischemic myocardial insult or respiratory failure.

Narrow-Complex (<0.09 Second) Tachycardia

RateA rate of >220 beats/min in an infant or >180 beats/min in a child, with a rate out of proportion to clinical status, is likely SVT

P wavemorphology usually varies from sinus

QRSnormal (unless associated with aberrant ventricular conduction).

ConductionP-R interval depends on the status of AV conduction tissue and atrial rate: may be normal, abnormal, or not measurable.

Supraventricular Tachycardia

Supraventricular Tachycardia

Monitor rhythm during therapy

Vagal stimulation:• Infants and young children: apply ice to the face

without occluding the airway • older children: carotid sinus massage or

Valsalva maneuvers

Do not apply pressure to the eye because this can damage the retina.

Supraventricular Tachycardia

Pharmacologic Cardioversion: Adenosine : The drug of choice.

First dose: 0.1 mg/kg (maximum 6 mg)Second dose: 0.2 mg/kg (maximum 12 mg)

Verapamil: Effective in older childrenDose: 0.1 to 0.3 mg/kg

Supraventricular Tachycardia

For a patient with SVT unresponsive to vagal maneuvers and adenosine:

• Amiodarone 5 mg/kg IO/IV • Procainamide 15 mg/kg IO/IV

IF the patient is hemodynamically unstable or if adenosine is ineffective:

synchronized cardioversion Start with a dose of 0.5 - 1 J/kg, increase the dose to 2 J/kg.

Sinus Tachycardia

Rate101-160/minP wavesinusQRSnormalConductionnormalRhythmregular

Sinus Tachycardia

• If the rhythm is sinus tachycardia, searchfor and treat reversible causes.(6 H,5T)

Wide-Complex (>0.09 Second) Tachycardia

VT

Hypotention

Hypotension is defined as a systolic blood pressure:

60 mm Hg in term neonates (0 to 28 days)

70 mm Hg in infants (1 month to 12 months)

70 mm Hg (2 age in years) in children 1 to 10 years

90 mm Hg in children 10 years of age

Wide-Complex Tachycardia

Hemodynamically unstable patients:Synchronized cardioversion 2–4 J/kg up to 10 J/kg

Hemodynamically stable patients:• Adenosine :useful in differentiating SVT from VT

• Amiodarone :5 mg/kg over 20 to 60 minutes

• Procainamide :15 mg/kg given over 30 to 60 minutes

QUESTION???

3 year old child with new-onset seizures, who developed sudden cardiac arrest in the ED

Pulseless VT

Treatment : Defibrillation First shock: 2 J/kg

Second shock: 4 J/kg up to 10 J/kg

After one shock:

Treatment:

• Check monitor lead

• Chest compression & CPR immediately

• Epinephrine.

5 year old child with cyanosis & agitation

Sinus Tachycardia

• Search for and treat reversible causes:OT> 40°C Fever is the caues of Sinus Tachycardia and shoud be

treated

8 year old child with new-onset palpitation

Supraventricular Tachycardia

• Hemodynamically stable:– Vagal stimulation– Adenosine

• Hemodynamically unstable:– Perform electric synchronized cardioversion Start with

a dose of 0.5 - 1 J/kg, increase the dose to 2 J/kg