Paeds resus

Question 1

Discuss most common causes of arrest in children

Answer 1

Traumatic
Most non traumatic cardiac arrest in children arise from respiratory aetiologies, drowning, asphyxia and resp failure. The typical progression is from respiratory failrue to shock and finally bradycardia and loss of circulation.

The most common presenting rhythym in children is asystole occuring in 2/3 of patients. PEA and bradycardia are the next most common

Question 2

Discuss utility of pulse check in children

Answer 2

Reasonable for emergency staff to have a 10 second pulse check –

In children in cardaic arrest ausculation of the heart or palpation of the apical impulse can be misleading as the above can be present in PEA without central output

Question 3

Discuss PALS

Answer 3

CPR 15:2 – 100-120

• when performed correctly deliver 1/3 of CO
• Can use ETCO2 as a marker of CPR – in the low flow state of CPR the flow of venous blood to the lungs serves as the rate limiting step rather than ventilation

Shock –> 4j/kg can increase if refractory to a max of 10J/kg or adult dosing
-largest pads that will fit on chest while not touching decrease impendence

Drugs:

• Epi 10mic/kg
• amio 5mg/kg
• lignocaine 1mg/kg loading followed by 20-50mic/kg infusion

ETT: size = (age/4)+4, at lips, depth (age/2) +`12
- once ETT in deliver breaths uninterrupted 10/min

Weight – (age +4) *2, Browselow-Luten tape
Blood volume = 75mL\kg

Family should be given the option to be present during a resus – can be asked to leave if they impede medical care

Question 4

Discuss fluid and blood product administration for paeds

Answer 4

Crystalloid 20 mL/kg for resuscitation
RBC units 10mL\kg
Platelets 10mL\kg
FFP 15mL\kg
Cryo 5mL\kg

Question 5

Discuss post arrest care in paeds

Answer 5

Post cardiac arrest patients develop a sepsis-like syndrome with elevations in inflammatory markers, myocardial dysfunction, systemic ischaemia and MOD

A: - should be secured and normocarbia should be maintained
b: Hyperoxemia and hypoxia should be avoided, aim for spo2 >94% and pao2 <300
C: post arrest hypotension is assoicated with increased mortality –> fluid bolusing and norad +-dobutamine to maintain perfusion
-end points normal lactate
-urine output 0.5-1ml/kg
D:normoglycaemia and electrolyte balance
E: Aim for t 36, nil strong evidence for cooling below this

ECMO if available

Question 6

Discuss cessation of resus

Answer 6

Nil clear cut guidlines 
Factors assocaited with poor outcome that can aid this decision include 
- Prolonged lenght of CPR 
-out of hospital cardiac arrest 
-initial cardiac rhythm 
Administration of multiple doses of EPI 
-ETCO2 <10 

Should be considered after 30 minutes of effort

Question 7

Discuss cold vs warm shock in children

Answer 7

Warm

• HD (high CO, low SVR)
• Clinical findings (widended pulse pressure, brisk cap refill, warm extremities, bounding pulse)
• Pathogens ( HAP, central line. mixed gram +ve/+ve)
• Pressor of choice (norad)

Cold 
-HD ( low CO, high SVR) 
Clinical ( narrow pulse pressure, delayed cap refill, cool mottled, cold extremities, CCF, rales, hepatomegaly, jugular venous distension) 
-pathogens (CAP) 
- Inotrope (epi, dobutamine, milrinone)

Question 8

Discuss management of Sepsis

Answer 8

Timely administration of ABs - within 1 hour
Fluid 20ml/kg pver 5-15 minutes –> reassess, urine output 0.5-1ml and normal lactate , Map >65
-after 40ml/kg of isotonic fluid or signs of overload start inotropes

Consider steroid dosing – dexamethason, nil sigifnciat evidence for or against but in refractory shock, should trial to exclude adrenoinsuffiency

Question 9

Discuss BRUE

Answer 9

A BRUE refers to an episode in an infant less than 12 months old which is:

Duration <1 minute (typically 20-30 seconds)
Sudden onset, accompanied by a return to a baseline state
Characterised by ≥1 of the following:
cyanosis or pallor
absent, decreased or irregular breathing
marked change in tone (hypertonia or hypotonia)
altered level of responsiveness
Not explained by identifiable medical conditions
Cause range from benign to life threatening

Critical causes not to miss include

• NAI
• Congenital heart disease
• reflux
• seizures
• respiratory illness

Question 10

Discuss disposition of BRUE

Answer 10

If all of the following are met and there are no concerning features on exmaintoin investigation is not required and patient can be discahrged with minotiring from family

1) Age >60
2) born >32 weeks and corrected gestational age >45 weeks
3) no CPR
4) first event

Unlikley to represent seriour underlying features
If any of the above are not met require paed review and investigation

Question 11

Discuss investifation of a non low risk Brue

Answer 11

For similar events that fall outside the low risk BRUE criteria, consider performing the following investigations

ECG (measure QT interval)
Nasopharyngeal sample for viruses and pertussis
Blood glucose
FBE and UEC if clinically indicate

Question 12

List normal vitals signs for ages

Answer 12

Newborn

• HR 100-160
• RR 50-70
• BP 40-60

<12 months
-HR 80-140
RR 30-40
BP 70-100

1-3 years
HR 80-130
RR 20-30
BP 70-110

3-6
HR 80-110
RR 20-30
BP 80-110

6-12
HR 70-100
RR 18-24
BP 80-120

12+
HR 60–90
RR 14-22
BP 100-120

Question 13

Discuss step by step

Answer 13

Identifies febrile infants <90 days old at low risk of invasive bacterial infections and those at high risk

1) Ill appearing - appearance, WOB or abnormalities in circulation
2) <21 days
3) Leukocyturia
4) Procalcitonin >0.5ng/ml
5) CRP >20 or WBC >10

If no to all risk of invasive bacterial infection is low nil need for full work up

Question 14

Discuss PERCARN for sepsis

Answer 14

Predicts risk of UTI, bacteremia or bacterial meningitis in febrile infants aged 29-60

1) Urinalysis positive
2) Neutrophils > 4
3) Procalcitonin >0.5ng/ml