Case 83 - Peds CPR

Question 1

what is the etiology of cardiac arrest in children?

Answer 1

1) Primary Factors

• respiratory failure
• shock
• sudden arrhythmias (Pulseless VT, VFIB)

2) Secondary Factors

• 5 H’s & 5 T’s

Question 2

In PALS, what is your compression/vent ratio, # of chest compressions per min, depth of chest compression, and ventilation with and without an advanced airway?

Answer 2

1) chest compresion / vent ratio
* 30:2 for 1 proider, 15:2 for 2 provider
2) number of chest compression
* push fast - > 100 compress / min

3) depth of compress (push hard)

• infant - 1.5 in
• child - 2 in
• (adult > 2 in )

4) ventilation

• no airway - each breath over sec in appropriate c/v ratio
• adv airway - 8-10 breaths per min

Question 3

How do you know if your CPR is effective?

Answer 3

1) ETCO2
* > 10 mm Hg
2) Aortic diastolic pressure
* > 20 mm Hg

Question 4

A 4 yr old child goes into V-fib, you have a manual defibrillator handy, what dose of shock will you give them?

Answer 4

• intial dose 2 J/kg
• if 2nd shock necessary - 4 J/kg

Question 5

4 year old child goes into v-fib, you only have an AED with adult pads only, do you still use this?

Answer 5

• defibrillation with an AED is a better option than no defibrillation at all
• Answer - YES USE ADULT PADS
  
  • with an AED, use an attenutated dose if available. If not, then shock with adult dose

Question 6

you cannot obtain IV access in a coding child, what is your next best option and where would you place it?

Answer 6

IO ACCESS

• sites - prox tibia (most common)
• other - ASIS, distal femur, distal tibia

Contraindications to IO

• facture of surrounding bone
• osteogensis imperfecta
• infection at site
• prior IO attempt at same site

Question 7

What is symptomatic bradycardia considered, and how is it managed in an infant?

Answer 7

• bradycardia age related
• premonitory for cardiac arrest
• HR < 60 in presence of cardipulmonary impairment (hypotension, acute altered mental status, shock)

Values

• premature = 120-160
• 0-3 months = 100 - 150
• 3 - 12 months = 90 - 120
• 1 - 3 yrs = 70 - 110

mgmt

• ensure adequate oxygenation and ventilation
  
  • kids have vagal reflex with hypoxia
• if symp brady persists -> CPR
• if no improvement -> 0.1 mg/kg EPI (1:10,000)
  
  • atropine 20 mcg/kG resered for cases of heightened vagal activity (intubaiton, suction, cholindergic overdose)
• if no improvment -> cardiac pacing

Question 8

how do you treat PEA?

Answer 8

PEA

• cardiac electrical activity on EKG with no associated pulse
• non-shockable rhythm

MGMT

• call for help, initiate ACLS protocol
• CPR
• obtain IV/IO access
• epi 0.1 mg/kg (1:10,000) q 3-5 min
• 2 min CPR, check rhythm, shockable or nonschockable, continue CPR
• 5 H’s & 5 T’s

Question 9

What are the disadvantages of administering meds via ETT?

Answer 9

• non-predictable blood levels, not reliable drug effect
• chest compressions must be stopped for ETT administration

Question 10

How do you manage vib/pulseless VT

Answer 10

• call for help
• initiate ACLS protocol
• obtain defibrillator, do not delay CPR in the meantime
• begin CPR
• shock once defib is placed on patient
  
  • 2 J/kg (1st shock)
• Resume CPR
• obtain IV/IO access
• Shock again
  
  • 4 J /kg (2nd shock)
• admin epi 0.1 mg/kg (1:10,000) q 3 - 5 min
  
  • epi given after 2nd shock because defib alone may result in life-sustainable rhythm
• If CPR continues, use other drugs:
  
  • Amio 5 mg/kg or Lido 1 mg/kg
• 5 H’s & 5 T’s

Question 11

How do you diferentiate betwen ST and SVT

Answer 11

ST

• p wave is present, normal
• usually due to dehydration, fever
• R-R interval ariable
• slower HR BPM than SVT
  
  • infant rate < 220 bpm
  • children rate < 180 bpm
• TX - treat underlying causes

SVT

• p wave not present (buried within QRS)
• R-R interval constant
• faster HR compared to ST
  
  • infant rate > 220 bpm
  • children rate > 180 bpm
• TX - break SVT cycle with vagal maneuver or meds

*

Question 12

how do you manage SVT in a child?

Answer 12

1) Hemodynamically stable or unstable

• unstable = hypotension, altered mental status, shock
  
  • sync cardioversion 1 J / kg

2) If stable, determine QRS widening

• Narrow complex SVT (QRS < 0.09 sec)
• Wide Complex SVT (QRS > 0.09 sec)
  
  • adults is 0.12 sec

3) narrow vs wide complex

Narrow

• vagal maneuvers
  
  • infant - small ice pack on face
  • child - carotid sinus massage, bear down
• obtain IV/IO Access
• Adenosine 0.1 mg/kg (if vagal does not work)
• Sync Cardiovert - if adenosine and vagal does not work
  
  • 1 J/kg

Wide

• stable or unstable
• unstable = hypotension, altered mental status, shock
  
  • shock
• stable - seek cardiac consult