Title: Pediatric Advanced Life Support

PCMC 26th COMPREHENSIVE REVIEW

Lecturer: Florentina Uy-Ty, MD

GOALS OF RESUSCITATION • Adolescents: Follow adult recommendations

To improve the quality of care provided to seriously ill or • Adults: Compressions should be at least
injured children resulting in improved outcome 2 inches (5 cm) but no more than
2.4 inches (6 cm)
High Quality CPR is the Foundation of Basic and Advanced Life
Support for Management of Cardiac Arrest EMPHASIS ON CHEST COMPRESSION DEPTH
• Difficult to judge compression depth without use of
Even the BEST Advanced Life Support Interventions will be feedback devices
INEFFECTIVE if Basic Life Support is of poor quality • Chest compression depth is more often too shallow than too
deep
BASIC LIFE SUPPORT (BLS) • A compression depth of approximately 2 inches (5 cm) is
• Check scene safety associated with greater likelihood of favorable outcomes
• Check responsiveness compared with shallower compressions
• Activate emergency response, ask for an AED • Research suggests potential injury when compressions are
• Check breathing and pulses simultaneously (5-10 seconds) too deep (greater than 2.4 inches or 6 cm)
• Infant: brachial
• Child: carotid CHEST COMPRESSION RATE
• Start high quality CPR • Deliver chest compressions at a rate of 100 to 120
compressions per minute
BLS HEALTHCARE PROVIDER
Pediatric Cardiac Arrest Algorithm for the Single Rescuer – CHEST RECOIL
2015 Update • Avoid leaning on the chest between compressions to allow
full chest wall recoil

MINIMIZING INTERRUPTIONS IN CHEST COMPRESSIONS

• All rescuers should minimize the frequency and duration of
interruptions in chest compressions
• Chest compression fraction (CCF) is the amount of time spent
doing high quality chest compressions during CPR
• The goal of a chest compression fraction is at least 60% is
recommended, and a goal of 80% is often achievable with
good teamwork

AVOID EXCESSIVE VENTILATION

• 1 rescuer: Begin with 30 compressions followed by 2 breaths
• 2 rescuers: Begin with 15 compressions followed by 2
breaths
• Hyperventilation is harmful to the patient. In each
ventilation, the intrathoracic pressure increases leading to a
decrease in venous return and resulting to a decrease in
cardiac output. In hyperventilation, there is a big chance to
push air into the stomach leading to distention of the
stomach and eventually causing vomiting and aspiration in
the patient. The distended stomach also pushes the
diaphragm leading to a smaller area for ventilation.

RECOMMENDED SYSTEMIC APPROACH TO A PATIENT

The PAT and the Primary, Secondary And Tertiary Surveys
CHARACTERISTICS OF A HIGH QUALITY CPR General assessment Airway, work of breathing, and circulation
1. Push hard Primary assessment Airway, breathing, circulation, disability, and exposure
a. Infant: at least 1.5 inches or 4 cm Secondary assessment SAMPLE history, focused physical exam, and bedside
glucose
b. Child: at least 2 inches or 5 cm Tertiary assessment Laboratory studies, x-rays, and other tests
2. Push fast: 100-120 compressions per minute CATEGORIZE ILLNESS BY TYPE AND SEVERITY
3. Allow complete chest recoil Respiratory Circulatory
4. Minimize interruptions: Limit to less than 10 seconds Respiratory distress or respiratory Compensated shcok or hypotensive
failure shock
5. Avoid excessive ventilation Upper airway obstruction Hypovolemic shock
a. 1 rescuer: 2 breaths after every 30 compressions Lower airy obsutrction Distributive shock
b. 2 rescuers: 2 breaths after every 15 compressions Lung tissue disease Cardiogenic shock
c. Give each breath over 1 second Disordered control of breathing Obstructive shock
Respiratory + Circulatory
including cardiopulmonary failure
CHEST COMPRESSION DEPTH
• Provide chest compressions at least one third AP See last page for complete table of initial impression, primary
diameter of chest in pediatric patients assessment and secondary assessment
• Infants: Approximately 1.5 inches (4 cm)
• Children: 2 inches (5 cm)

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 Title: Pediatric Advanced Life Support
PCMC 26th COMPREHENSIVE REVIEW
Lecturer: Florentina Uy-Ty, MD

ARRYTHMIA PEDIATRIC TACHYCARDIA WITH A PULSE ALGORITHM

ECG Rhythm Interpretation
1. Heart rate
2. Rhythm interval: regular or irregular
3. Presence of P-waves
4. QRS complex: narrow or wide

RHYTHM DISTURBANCES/ ELECTRICAL THERAPY

Use of Cardiac Monitor
Cable connections
• White lead on the patient’s right shoulder (RA)
• Red lead on the patient’s left lower ribs (LL)
• Black lead on the patient’s left shoulder (LA)

Steps in operating the cardiac monitor

1. Turn on the monitor
2. Adjust device into manual mode
3. Display rhythm in standard monitoring lead (lead II)

Normal Heart Rate

Age Awake Sleeping
Newborn – 3 months 85 – 205 80 – 160
3 months – 2 years 100 – 190 75 – 160
2 years – 10 years 60 – 140 60 – 90
> 10 years 60 – 100 50 – 90 MAJOR AND NEW UPDATES ON 2020 AHA GUIDELINES
Changes to the Assisted Ventilation Rate
See last page for complete table of rhythm disturbances Rescue breathing
• Old: If there is a palpable pulse 60 bpm or greater but there is
PEDIATRIC CARDIAC ARREST ALGORITHM inadequate breathing, give rescue breaths at a rate of about
12 to 20 breaths per minute (1 breath every 3-5 seconds)
until spontaneous breathing resumes
• 2020: For infants and children with a pulse but absent or
inadequate respiratory effort, it is reasonable to give 1
breath every 2 to 3 seconds (20 to 30 breaths per minute)
• New data show that higher ventilation rates at least 30
breaths per minute in infants and 25 breaths per minute in
children are associated with improved rates of ROSC for IHCA

Ventilation rate during CPR with an advanced airway

• Old: If the infant or child is intubated, ventilate at a rate of
about 1 breath every 6 seconds (10 breaths per minute)
without interrupting chest
• 2020: When performing CPR in infants and children with an
advanced airway, the recommended rate of ventialtion is 1
breath every 2 to 3 seconds (20 to 30 breaths per minute).
Rates exceeding these recommendations may compromise
hemodynamics

Cuffed Endotracheal Tubes (ETTs)

• Old: Both cuffed and uncuffed ETTs are acceptable for
intubating infants and children. In certain circumstances (e.g.
poor lung compliance, high airway resistance, or a large
glottic air leak) a cuffed ETT may be preferable to an uncuffed
tube, provided that attention is paid to [ensuring
appropriate] ETT size, position, and cuff inflation
• 2020: Choose cuffed ETTs over uncuffed ETTs for intubating
infants and chuldren. When a cuffed ETT is used, attention
should be paid to ETT size, position, and cuff inflation
pressure (usually < 20 to 25 cm H2O)
• Several studies and systematic review support the safety of
cuffed ETT and demonstrate decreased need for
reintubation
• Cuffed tubes may decrease the risk of aspiration

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 Title: Pediatric Advanced Life Support
PCMC 26th COMPREHENSIVE REVIEW
Lecturer: Florentina Uy-Ty, MD

• Subglottic steonis is rare when cuffed tubes are used in Corticosteroid administration
children • 2020: For infants and children with septic shock
unresponsive to fluids and requiring vasoactive support, it
Cricoid Pressure during Intubation may be reasonable to consider stress-dose corticosteroids
• Old: Routine use of cricoid pressure is not recommended
during endotracheal intubation of pediatric patients Hemorrhagic Shock
• 2020: There is insufficient evidence to recommend routine • 2020: Among infants and children with hypotensive
application of cricoid pressure to prevent aspiration during hemorrhagic shock following trauma, it is reasonable to
endotracheal intubation in children administer blood products, when available, instead of
crystalloid for ongoing volume resuscitation
Emphasis on Early Epinephrine Administration
• Old: It is reasonable to administer epinephrine in pediatric
cardiac arrest
• 2020: For pediatric patients in any setting, it is recommended
to administer the initial dose of epinephrine within 5
minutes from the start of chest compressions.

Invasive Blood Pressure Monitoring to Assess CPR Quality

• 2020: For patients with invasive hemodynamic monitoring in
place at the time of cardiac arrest, it may be recommneded
for rescuers to use blood pressure to guide CPR quality
• Rates of survival with favorable outcome if diastolic pressure
was at least: 25 mmHg in infants, 30 mmHg in children

Detecting and Treating Seizures after ROSC

• Old: An electroencephalography for the diagnosis of seizure
should be promptly performed and interpreted and then
should be monitored frequently or continuously in comatose
patients after ROSC
• 2020: 1. When resources are available, continuous
electroencephalography monitoring is recommended for the
detection of seizures following cardiac arrest in patients with
persistent encephalopathy
• 2. It is recommended to treat clinical seizures following
cardiac arrest
• 3. It is recommended to treat nonconvulsive status
epilepticus following cardiac arrest in consultation with
experts

Evaluation and Support for Cardiac Arrest Survivors

• 2020: It is recommended to refer pediatric cardiac arrest
survivors for ongoing neurologic evaluation for at least the
first year after cardiac arrest
• It is recommended that pediatric cardiac arrest survivors be
evaluated for rehabilitation services

Septic Shock
Fluid boluses
• Old: Administration of an initial fluid bolus of 20 mL/kg to
infants and children with shock is reasonable, including those
with conditions such as severe sepsis, severe malaria, and
dengue
• 2020: In patients with septic shock, it is reasonable to
administer fluid in 10 mL/kg or 20 mL/kg aliquots with
frequent reassessment

Choice of vasopressors
• 2020: In infants and children with fluid-refractory septic
shock, it is reasonable to use either epinephrine or
norepinephrine as an initial vasoactive
• If epinephrine or norepinephrine are not available, dopamine
may be considered

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 Title: Pediatric Advanced Life Support
PCMC 26th COMPREHENSIVE REVIEW
Lecturer: Florentina Uy-Ty, MD

INITIAL IMPRESSION
EVALUATE IDENTIFY INTERVENE
• Respiratory distress • Call for HELP
• Respiratory failure • Activate emergency response system
• Shock • Start supplemenetal oxygen
A Appearance o Non-rebreather mask for 11-15 LPM
o Bag-mask venitalation
B Breathing o Bag-tube ventilation
C Color • Hook to cardiac monitory and pulse oximeter
Life threatening condition Basic life support
• With signs of life
• Without signs of life
PRIMARY ASSESSMENT
EVALUATE IDENTIFY INTERVENE
SEVERITY TYPE
A Airway Respiratory UAO: Upper airway obstruction Oxygenation
• Maintainable/unmaintainable • Distress LAO: Lower airway onsctruction • Continue or shift?
• Failure LTD: Lung tissue disease
B Breathing DCB: Disordered control of breathing
• Respiratory rate, O2 saturation, work of
breathing, breath sounds
C Circulation Shock HS: Hypovolemic shock Monitor (Interpretation)
• Heart rate, blood pressure, central and • Compensated OS: Obstructive shock • Heart rate
peripheral pulses, capillary refill time • Hypotensive DS: Distributive shock • Rhythm: regular or irregular
CS: Cardiogenic shock • P wave: present or absent
D Disability • QRS complex: narrow or wide
• A – Awake, V – Verbal, P – Pain, U –
• Interpretation?
Unresponsive
E Exposure IV/IO
• Temperature, blood glucose, rash, trauma • Start or prepare
SECONDARY ASSESSMENT
EVALUATE IDENTIFY INTERVENE
S Signs and symptoms Final identification Case specific intervention
Respiratory
A Allergies Severity and type
M Medications Shock
P Past medical history Severity and type
L Last oral intake
E Events (onset)
HEAD-TO-TOE PHYSICAL EXAMINATION
DIAGNOSTICS TESTS IDENTIFY/INTERVENE
RE-EVALUATE – IDENTIFY – INTERVENE AFTER EACH INTERVENTION

RHYTHM DISTURBANCES
Normal Sinus Rhythm Sinus Tachycardia Sinus Bradycardia Supraventricular Ventricular Tachycardia Ventricular Fibrillation
Tachycardia
Rate Variable with age Infants: < 200 bpm < 60 bpm Infants: > 220 bpm Above normal for age 150-500 bpm
Children: < 180 bpm Children: > 180 bpm (100-250 bpm)
Rhythm Regular Variable RR interval, Regular Regular Regular Irregular, chaotic
constant PR
P wave Present Present Present Absent Absent No identifiable p wave
QRS complex Narrow Narrow Narrow Narrow Wide No identifiable QRS
complex

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