Pediatric Resuscitation & Emergencies

Question 1

Oxygen

Answer 1

Ventilate w/ 100% FiO2

Question 2

Epinephrine

Answer 2

Hypotension 1mcg/kg

Cardiac arrest 10mcg/kg repeat Q3-5min as needed

Question 3

Atropine

Answer 3

Symptomatic bradycardia 0.02mg/kg or 20mcg/kg

Max dose 1mg (child) or 2mg (adolescent)

Question 4

Adenosine

Answer 4

100mcg/kg rapid IV bolus & flush
Max 6mg

Double 2nd dose 200mcg/kg
Max 12mg

Question 5

Amiodarone

Answer 5

5mg/kg IV
Max 300mg
Vfib or Vtach

Question 6

Lidocaine

Answer 6

1mg/kg IV followed by 20-50mcg/kg/min on the infusion pump

Question 7

Magnesium

Answer 7

25-50mg/kg IV
Max 2g
Torsades de pointes

Question 8

Bicarbonate

Answer 8

1-2mEq/kg IV based on ABG results

Question 9

Calcium Chloride

Answer 9

CENTRAL

10-20mg/kg IV (0.1-0.2mL/kg 10% solution)

Question 10

Calcium Gluconate

Answer 10

Peripheral

30-60mg/kg IV (0.3-0.6mL/kg 10%)

Question 11

Procainamide

Answer 11

5-15mg/kg IV loading dose over 30-60min then 20-80mcg/kg/min on the infusion pump
EKG monitoring required
Caution: Monitor for hypotension or prolonged QT

Question 12

Cardiac Arrest Risk Factors

Answer 12

Cardiac surgery
Infants < 1mos old
ASA > 3
Prematurity
Congenital heart disease (aortic stenosis, cardiomyopathy, single ventricle)
Emergency procedures

Question 13

Medication-Related Cardiac Arrest Etiologies

Answer 13

Anesthetic overdose
Succinylcholine
Neostigmine induced
Medication error/swap
Drug reactions
Inadvertent IV local anesthetic injection
LAST
High spinal
Inadequate paralytic reversal
Opioid-induced respiratory depression

Question 14

Cardiovascular Causes

Answer 14

Hypovolemia
Hemorrhage
Inadequate volume administration
Hyperkalemia
Hypocalcemia
Hypoglycemia
Vagal
Central line → dysrhythmias, hemorrhage, tamponade
Embolism (air, clot, fat)
Malignant hyperthermia
Hypothermia
Myocardial infarction
Sepsis
Adrenal insufficiency

Question 15

Respiratory Causes

Answer 15

Inadequate oxygenation/ventilation
Inability to ventilate i.e. laryngospasm, bronchospasm, or mediastinal mass
ETT misplacement, kink, plug, or accidental extubation
Difficult airway anatomy
Residual neuromuscular blocker
Aspiration
Pneumothorax

Question 16

ROSC

Answer 16

Return of spontaneous circulation

Restoration a perfusing rhythm & BP that persists at least 20min post arrest

Question 17

Asystole

Outside Hospital

Answer 17

Associated w/ poor ROSC & survival

Often d/t prolonged hypoxia & represents terminal rhythm

Question 18

Asystole

OR

Answer 18

Initial rhythm response to vagal stimulation
More likely to reverse & associated w/ good prognosis
Examples: Insufflation or carotid massage

Question 19

Prolonged Arrest

Answer 19

Lengthy low-flow intervals, inadequate perfusion, myocardial and cerebral injury

Question 20

What timeframe predicts mortality?

Answer 20

CPR > 15min

Question 21

How many CPR hours have been reported in anesthesia-related events w/ good outcome?

Answer 21

3 hours

Question 22

When to activate ECMO?

Answer 22

After 10min failed resuscitation w/ reversible conditions

Question 23

Periop Cardiopulmonary Arrest

Answer 23

• Inhalational induction 25% (laryngospasm, agent overdose, depressed myocardial function)
• Craniofacial or spine surgery d/t hypovolemia, blood loss, or VAE
• Hyperkalemia d/t rapid RBC transfusion
• VP shunt malfunction ↑ICP
• LAST
• Anaphylaxis

Question 24

LAST Treatment

Answer 24

IV 20% lipid emulsion 1.5mL/kg over 1min

Followed by 0.25mL/kg/min infusion over 10min

Question 25

Cardiopulmonary Resuscitation

Answer 25

1. Recognize need CPR 2. Know how to correctly perform (oxygenation, ventilation, circulation, defibrillation/cardioversion) 3. Vascular access 4. Medications 5. Teamwork 6. Documentation 7. Post-resuscitation care 8. Self-care post critical incident

Question 26

When to begin chest compressions?

Answer 26

HR < 60bpm | Children are HR dependent

Question 27

Newborn Pulse Check

Answer 27

Umbilicus EKG Brachial

Question 28

Infant Pulse Check

Answer 28

Brachial or femoral artery

Question 29

Child Pulse Check

Answer 29

Carotid or femoral

Question 30

Other considerations during pediatric emergency include:

Answer 30

100% FiO2 | Discontinue all anesthetics

Question 31

Newborn BLS

Answer 31

``` Compressions 90/min 1/3 chest anterior-posterior diameter 2 encircling thumbs Lower 1/3 sternum Breaths 30/min ```

Question 32

Infant BLS

Answer 32

``` Compressions 100-120/min 1/3 chest AP diameter (4cm) 2 encircling thumbs Lower 1/3 sternum Breaths 10/min ```

Question 33

Child BLS

Answer 33

``` Compressions 100-120/min 1/3 chest AP diameter (5cm) 1 or 2 hands Lower 1/3 sternum Breaths 10/min ```

Question 34

Adolescent BLS

Answer 34

``` Compressions 100-120/min Depth 5-6cm 2 hands Lower 1/2 sternum Breaths 10/min ```

Question 35

When to intubate?

Answer 35

``` Recommended during CPR in the OR Ensure adequate ventilation ↓aspiration risk Minimal interruptions to compressions w/ trained anesthesia providers Check correct placement ```

Question 36

ETT Medications

Answer 36

``` Lidocaine Epinephrine Atropine Naloxone Surfactant Albuterol Vasopressin Diazepam (Valium) ```

Question 37

Defibrillation

Answer 37

V fib or pulseless V tach 2-4 J/kg up to 10 J/kg or maximum adult dose

Question 38

Cardioversion

Answer 38

Synchronized rhythms - A fib, A flutter, or SVT 0.5-1 J/kg Repeat dose 2 J/kg

Question 39

Next step when unable to obtain peripheral venous access w/in 90sec?

Answer 39

Another route Drugs via ETT Intraosseous (IO) Femoral vein

Question 40

Appropriate Flush Volume

Answer 40

0.25mL/kg NS Infants 5mL Children 10mL

Question 41

Care After ROSC

Answer 41

Titrate FiO2 (aim Pox 94-99%) Assess rebound arrest - hyperkalemia treatment (dialysis) or needle decompression for tension pneumo (chest tube) Confirm ETT & line placement Avoid hypothermia, hyperglycemia, & seizures Cooling after arrest? Update the family ICU transfer