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
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