Cardiopumonary Arrest

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P.A.L.S
Pediatric Advanced Life Support
Cardiopumonary Arrest
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Pediatric cardiac arrest Shout for help, Activate
emergency response

• Start CPR
• Give oxygen
• Attach monitor/defibrillator

rhythm Shockable?
Yes
No
VF/VT
Asystole /PEA
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• Asystole and Pulseless Electrical Activity

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Asystole or Pulseless Electrical Activity
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Asystole / Pulseless Electrical Activity
Resume CPR immediately for 2 min IV/IO
available Epinephrin 0.01 mg/kg (0.1 mL/kg of
110 000 solution) Repeat every 3 to 5 min No
IV/IO ETT Ephinephrin 0. 1 mg/kg (0.1 mL/kg of
11000 solution) of 11000 solution) Consider
advanced airway
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Give 2 min of CPR
rhythm Shockable?
Not Shockable
Shockable
If asystole or pulsless CPR and Epinephrin If
pulse present post resuscitation care Threat
reversible causes
DC shock
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Reversible Causes
5T 6H
Tension pneumothorax Hypoxia
Tamponade Hypovolaemia
Toxins Hyper/hypokalaemia
Thrombosis,coronary Hypothermia
Thrombosis, pulmonary Hypoglycemia
Hydrogen ion (acidosis)
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Pediatric cardiac arrest Shout for help, Activate
emergency response

• Start CPR
• Give oxygen
• Attach monitor/defibrillator

rhythm Shockable?
Yes
No
VF/VT
Asystole /PEA
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• Ventricular Fibrillation/Pulseless Ventricular
  Tachycardia

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Ventricular Tachycardia
usually between 100 to 220/bpm, but can be as rapid as 250/bpm Rate
obscured if present and are unrelated to the QRS complexes. P wave
wide and bizarre morphology QRS
as with pvc Conduction
three or more ventricular beats in a row may be regular or irregular. Rhythm
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Ventricular Fibrillation
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Ventricular Fibrillation
unattainable Rate
may be present, but obscured by ventricular waves P wave
not apparent QRS
chaotic electrical activity Conduction
chaotic electrical activity Rhythm
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VF/VT
shock

• First shock 2 J/kg
• Second shock 4 J/kg
• Subsequent energy levels may be
• considered, not to exceed 10 J/kg or the
• adult maximum dose

Give 2 min of CPR
Not Shockable
rhythm Shockable?
Shockable
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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.

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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.

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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.

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Defibrillators

• Paddle Size
• Two sizes of hand-held paddle
• Adult size 8 to 10 cm for children gt 10
  kg
• ( approximately 1 year)
• Infant size 4-5 cm for infants lt 10 kg

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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

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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.

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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.

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Pediatric Arrhythmias

• Bradycardia
• Tachycardia

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Heart Rate
Heart Rate (beats/min) Age
130-190 Birth4 wk
125-185 13 mo
110-165 36 mo
105-195 612 mo
100-155 13 y
70-120 35 y
60-110 58 y
55-100 812 y
50-100 1216 y
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Bradycardia

• Emergency treatment of bradycardia is indicated
  when the rhythm results in hemodynamic
  compromise
• Hypotension
• Acutely altered mental status
• Signs of shock

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Atropine

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

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Bradycardia

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

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Narrow-Complex (lt0.09 Second) Tachycardia
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Supraventricular Tachycardia
A rate of gt220 beats/min in an infant or gt180 beats/min in a child, with a rate out of proportion to clinical status, is likely SVT Rate
morphology usually varies from sinus P wave
normal (unless associated with aberrant ventricular conduction). QRS
P-R interval depends on the status of AV conduction tissue and atrial rate may be normal, abnormal, or not measurable. Conduction
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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.

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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 children
• Dose 0.1 to 0.3 mg/kg

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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.

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Sinus Tachycardia
101-160/min Rate
sinus P wave
normal QRS
normal Conduction
regular Rhythm

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Sinus Tachycardia

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

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Wide-Complex (gt0.09 Second) Tachycardia
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VT
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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

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Wide-Complex Tachycardia

• Hemodynamically unstable patients
• Synchronized cardioversion 24 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

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

• Treatment Defibrillation
• First shock 2 J/kg
• Second shock 4 J/kg up to 10 J/kg

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After one shock
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Treatment

• Check monitor lead
• Chest compression CPR immediately
• Epinephrine.

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5 year old child with cyanosis agitation
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Sinus Tachycardia

• Search for and treat reversible causes
• OTgt 40C
• Fever is the caues of Sinus Tachycardia and shoud
  be treated

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8 year old child with new-onset palpitation
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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