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Pediatric advanced life support updates 2020
- 1. PEDIATRIC LIFE SUPPORT UPDATES 2020 EDITED &COLLECTED BY Abd Elaal Mohamed Elbahnasy Emergency Medicine Registrar Egypt, Middle East DR ABD ELAAL ELBAHNASY
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- 5. Cardiac arrest in infants and children does not usually result from a primary cardiac cause; rather, it is the end result of progressive respiratory failure or shock. In these patients, cardiac arrest is preceded by a variable period of deterioration, which eventually results in cardiopulmonary failure, bradycardia, and cardiac arrest In children with congenital heart disease, cardiac arrest is often due to a primary cardiac cause, although the etiology is distinct from adults. DR ABD ELAAL ELBAHNASY
- 6. High quality CPR (1) adequate chest compression depth (2) optimal chest compression rate (3) minimizing interruptions in CPR (ie, maximizing chest compression fraction or the proportion of time that chest compressions are provided for cardiac arrest) (4) allowing full chest recoil between compressions (5) avoiding excessive ventilation. DR ABD ELAAL ELBAHNASY
- 7. Components of high quality CPR DR ABD ELAAL ELBAHNASY
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- 9. Initiation of CPR DR ABD ELAAL ELBAHNASY
- 10. CPR technique DR ABD ELAAL ELBAHNASY
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- 18. airway HEAD TILT CHIN LIFT IF TRAUMA PATIENT JAW THRUST IF TRAUMA AND JAW THRUST NOT OPEN THE AIRWAY USE HEAD TILT CHIN LIFT DR ABD ELAAL ELBAHNASY
- 19. Advanced airway Most pediatric cardiac arrests are triggered by respiratory deterioration. Airway management and effective ventilation are fundamental to pediatric resuscitation. Although the majority of patients can be successfully ventilated with bag-mask ventilation Advanced airway interventions, such as supraglottic airway (SGA) placement or endotracheal intubation (ETI), may improve ventilation, reduce the risk of aspiration, and enable uninterrupted compression delivery. DR ABD ELAAL ELBAHNASY
- 20. Drug administration Don’t give routine sodium bicarbonate unless TCA toxicity or sever hyperkalemia Don’t give ca unless hypocalcemiaor ca channel blocker toxicity ,hyperkalemia or hypermagnesmia Adminster epinephrine iv or io Adminster initial dose within 5 min from chest compression Repeat epinephrine every 4 min DR ABD ELAAL ELBAHNASY
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- 22. MANAGEMENT OF VF/p VT Initial dose of energy 2-4j/kg For refractory VF increase the dose of defibrillation to 4j/kg Not exceed 10 j/kg or adult dose DR ABD ELAAL ELBAHNASY
- 23. Chain of survival Historically, cardiac arrest care has largely focused on the management of the cardiac arrest itself, highlighting high-quality CPR, early defibrillation, and effective teamwork. However, there are aspects of prearrest and postarrest care that are critical to improve outcomes For both chains of survival, activating the emergency response is followed immediately by the initiation of high-quality CPR. If help is nearby or a cell phone is available, activating the emergency response and starting CPR can be nearly simultaneous. However, in the out-of- hospital setting, a single rescuer who does not have access to a cell phone should begin CPR (compressions-airway-breathing) for infants and children before calling for help because respiratory arrest is the most common cause of cardiac arrest and help may not be nearby DR ABD ELAAL ELBAHNASY
- 24. Perform CPR until the device ready Single shock followed by immediate chest compression Minimize interruption Use pediatric attenuator if infant or children less than 8 y manual defibrillator is recommended If manual defib or AED with pediatric attenuation not available use the usual AED DR ABD ELAAL ELBAHNASY
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- 27. POST–CARDIAC ARREST CARE TREATMENT AND MONITORING DR ABD ELAAL ELBAHNASY
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- 29. Maintain normoxemia Wean oxygen at target of oxyhemoglobin 94-99% Limit exposure to sever hypercapnia or hypocapnia DR ABD ELAAL ELBAHNASY
- 30. EEG monitoring is recommended for detection of seizures Treat seizures following cardiac arrest Treat nonconvulsive status epilepticus following arrest in consultation with experts DR ABD ELAAL ELBAHNASY
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- 32. EVALUATION OF SUDDEN UNEXPLAINED CARDIAC ARREST DR ABD ELAAL ELBAHNASY
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- 34. RESUSCITATING THE PATIENT IN SHOCK DR ABD ELAAL ELBAHNASY
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- 36. Reassess the patient after fluid bolus Use isotonic or colloid for resuscitarion In septic shock administer 10 ml/kg or 20 ml/kg with assessment DR ABD ELAAL ELBAHNASY
- 37. Use epinephrine and norepinephrine in fluid refractory septic shock Give stress dose of corticosteroid for infant and children unresponsive to fluid and requiring vasoactive support If epinephrine and norepinephrine not available use dopamine DR ABD ELAAL ELBAHNASY
- 38. Early expert consultation Use epinephrinemdopamine,dobutamine or milrinone as inotropic DR ABD ELAAL ELBAHNASY
- 39. Give blood products instead of crystalloid in hypotensive hemorrhagic shoch DR ABD ELAAL ELBAHNASY
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- 41. TREATMENT OF RESPIRATORY FAILURE DR ABD ELAAL ELBAHNASY
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- 43. Rescue breathing if pulse presenr with absent respiration Give 1 breath every 2 to 3 sec 20-30 breath/min DR ABD ELAAL ELBAHNASY
- 44. Mild FABO Sever FABO IN CHILD SEVER FABO unresponsive ENCOURAGE COUGH ABDOMINAL THRUST 5 BACK SLAPS +5 CHEST COMPRSSION Sever FABO IN INFANT CPR with out pulse check After 2 min CPR activate emergency response system Try remove F B DR ABD ELAAL ELBAHNASY
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- 48. INTUBATION DR ABD ELAAL ELBAHNASY
- 49. Use cuffed ETTs for intubating infant and children Cricoid pressure during bag mask ventilation is considered to reduce gastric insufflation Routine use of cricoid pressure not recommended during intubation DR ABD ELAAL ELBAHNASY
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- 52. MANAGEMENT OF BRADYCARDIA DR ABD ELAAL ELBAHNASY
- 53. Bradycardia associated with hemodynamic compromise, even with a palpable pulse, may be a harbinger for cardiac arrest. As such, bradycardia with a heart rate of less than 60 beats per minute requires emergent evaluation for cardiopulmonary compromise If cardiopulmonary compromise is present, the initial management in the pediatric patient requires simultaneous assessment of the etiology and treatment by supporting airway, ventilation, and oxygenation. If bradycardia with cardiopulmonary compromise is present despite effective oxygenation and ventilation, CPR should be initiated immediately. DR ABD ELAAL ELBAHNASY
- 54. Give atropine if the cause increase vagal tone or primary AV block If HR less than 60 despite effective ventilation with oxygen atart CPR If brady cardia persist give epinephrineif no response consider transcutaneous pacing DR ABD ELAAL ELBAHNASY
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- 56. TACHYARRHYTHMIAS DR ABD ELAAL ELBAHNASY
- 57. Regular, narrow-complex tachyarrhythmias (QRS duration 0.09 seconds or less) are most commonly caused by re-entrant circuits, although other mechanisms (eg, ectopic atrial tachycardia, atrial fibrillation) sometimes occur. Regular, wide-complex tachyarrhythmias (greater than 0.09 seconds) can have multiple mechanisms, including supraventricular tachycardia (SVT) with aberrant conduction or ventricular tachycardia. DR ABD ELAAL ELBAHNASY
- 58. If iv/io available give adenosine Hemodynamic stable svt not responding to vagal maneuver or adenosine ,expert consultation recommended If hemodynamic unstable SVT perform cardioversion 0.5/1j/kg if unsuccessful increase the dose to 2 j/kg If no response and no expert consultation available try procainamide or amiodarone DR ABD ELAAL ELBAHNASY
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- 62. MYOCARDITIS DR ABD ELAAL ELBAHNASY
- 63. Fulminant myocarditis can result in decreased cardiac output with end- organ compromise; conduction system disease, including complete heart block; and persistent supraventricular or ventricular arrhythmias, which can ultimately result in cardiac arrest.1 Sudden onset of heart block and multifocal ventricular ectopy in the patient with fulminant myocarditis should be considered a prearrest state DR ABD ELAAL ELBAHNASY
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- 65. Pulmonary hypertension Rare disease pulmonary hypertension is idiopathic or associated with chronic lung disease; congenital heart disease; and, rarely, other conditions, such as connective tissue or thromboembolic disease. DR ABD ELAAL ELBAHNASY
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- 67. MANAGEMENT OF TRAUMATIC CARDIAC ARREST Thoracic injury should be suspected in all thoracoabdominal trauma because tension pneumothorax, hemothorax, pulmonary contusion, or pericardial tamponade may impair hemodynamics, oxygenation, and ventilation. DR ABD ELAAL ELBAHNASY
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- 70. TOP 10 TAKE-HOME MESSAGES 1. High-quality cardiopulmonary resuscitation (CPR) is the foundation of resuscitation. New data reaffirm the key components of high-quality CPR: providing adequate chest compression rate and depth, minimizing interruptions in CPR, allowing full chest recoil between compressions, and avoiding excessive ventilation. 2. A respiratory rate of 20 to 30 breaths per minute is new for infants and children who are (a) receiving CPR with an advanced airway in place or (b) receiving rescue breathing and have a pulse. 3. For patients with nonshockable rhythms, the earlier epinephrine is administered after CPR initiation, the more likely the patient is to survive. 4. Using a cuffed endotracheal tube decreases the need for endotracheal tube changes. 5. The routine use of cricoid pressure does not reduce the risk of regurgitation during bag-mask ventilation and may impede intubation success. 6. For out-of-hospital cardiac arrest, bag-mask ventilation results in the same resuscitation outcomes as advanced airway interventions such as endotracheal intubation. DR ABD ELAAL ELBAHNASY
- 71. 7. Resuscitation does not end with return of spontaneous circulation (ROSC). Excellent post–cardiac arrest care is critically important to achieving the best patient outcomes. For children who do not regain consciousness after ROSC, this care includes targeted temperature management and continuous electroencephalography monitoring. The prevention and/or treatment of hypotension, hyperoxia or hypoxia, and hypercapnia or hypocapnia is important. 8. After discharge from the hospital, cardiac arrest survivors can have physical, cognitive, and emotional challenges and may need ongoing therapies and interventions. 9. Naloxone can reverse respiratory arrest due to opioid overdose, but there is no evidence that it benefits patients in cardiac arrest. 10. Fluid resuscitation in sepsis is based on patient response and requires frequent reassessment. Balanced crystalloid, unbalanced crystalloid, and colloid fluids are all acceptable for sepsis resuscitation. Epinephrine or norepinephrine infusions are used for fluid-refractory septic shock. DR ABD ELAAL ELBAHNASY
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