Pediatric

Emergencies
1. Perform primary assessment
Once the child has been approached safely and been tested for unresponsiveness, assessment and
treatment follow the familiar ABC pattern.
1. Initial approach: SSS
a. BLS first
b. EMS activation first
2. Initial assessment
a. Are you alright?
b. Airway
c. Breathing
i. 5 initial rescue breaths
d. Circulation
i. Signs of life
ii. Chest compressions [Infant vs Child & Ratios]
e. Continuing CPR
f. Age definitions
g. Recovery position
h. Lay rescuers
i. Automatic external defibrillator in children
BLS Algorithm Initial SSS Approach
2. Perform head tilt/chin lift and jaw thrust

An obstructed airway may be the primary problem, and correction of the obstruction can
result in recovery without further intervention. If a child is not breathing, it may be because
the airway has been blocked by the tongue falling back and obstructing the pharynx.

If a child is having difficulty breathing, but is conscious, then transport to the hospital should
be arranged ASAP. A child will often find the best position to maintain his or her airway, and
should not be forced to adopt a position that may be less comfortable. Attempts to improve a
partially maintained airway in a conscious child in an environment where immediate
advanced support is not available can be dangerous, because total obstruction may occur.
Head Tilt/Chin Lift
Manoeuvre

https://www.facebook.com/CPRKids/
videos/in-drsabcd-a-airway-this-
short-video-demonstrates-the-
difference-in-opening-
the-/367100301706234/
Why the Difference
in Position?
In infants (<1 year), the aim is for a neutral
position due to their relatively short and fat
necks. In older children, a 'sniffing' position is
desirable as their necks need to be tilted
back to open their airways. It’s anatomical.
Jaw Thrust
Infant

Children
If the head tilt/chin lift manoeuvre is not
possible or is contraindicated because of a
suspected neck injury, then the jaw thrust
manoeuvre can be performed. This technique
may be easier if the rescuer’s elbows are resting
on the same surface as the child is lying on. A
small degree of head tilt may also be applied if
there is no concern about neck injury.
On rare occasions, it may not be possible to
control the airway with a jaw thrust alone in
trauma. In these circumstances, an open airway
takes priority over cervical spine risk and a
gradually increased degree of head tilt may be
tried.
3. Examine the presence of regular and effective respiration

Assess the patient's level of consciousness, airway patency, breathing, and circulation.
Check vital signs such as blood pressure, heart rate, and respiratory rate.

Efforts of breathing,
respiratory rate, recessions,
Inspiratory or expiratory noise
grunting
accessory muscle use and flaring
gasping and efficacy of breathing

Efficacy of breathing: e.g: degree of chest expansion

Effects of other organs: heart rate, skin colour, mental status

4. Demonstrate administration
of 2 rescue breaths
1) Open the airway

2) Check for breathing and a pulse

3) Pinch and seal

4) Provide a rescue breath

5) Give more breaths

 5. Perform back slap and
chest thrust on a doll
Back slap:
Infant is placed along one arm with the head
down.
Keep jaw open with supporting arm
Rest supporting arm on their thighs
Perform 5 back blows with the heel of the
free hand between shoulder blades

Chest thrusts:
Infant is placed along one arm with the head down
but face up.
5 sharp chest thrusts are with 2 fingers on cardiac
compression landmarks at a slower rate (1 per
second)
6. Identify nasal cannula, face masks, high flow masks
and self-inflating bag.
a) Nasal cannula
A nasal cannula is a medical device to provide supplemental
oxygen therapy to people who have lower oxygen levels.
Types:
High flow nasal cannulas (HFNC) Low flow nasal cannulas (LFNC)

They don't provide humidified or

These devices blow humidified,
heated oxygen. So, they often dry
heated oxygen into the nostrils.
out the nasal passages. This can
lead to bleeding or irritation

Can only deliver a nasal cannula

They can deliver up to 60 liters of
flow rate of 4-6 liters of oxygen
oxygen per minute.
per minute.
Indication: Risk.
Function: If the patient has Abdominal distension.
trouble breathing or doesn’t have Children or people undergoing anesthesia are
enough oxygen in the blood. at particular risk of abdominal distension, or
bloating of the stomach.
Given to patient that has : Other devices that deliver oxygen maintain a
Respiratory failure higher level of positive airway pressure and
Chronic obstructive carry no risk of distension. However, HFNCs
pulmonary disease (COPD) have lower positive airway pressure which can
Heart failure allow some gas to get into the digestive
Sleep apnea system, causing abdominal bloating.
Collapsed lung
Pneumonia Nasal injury or irritation.
COVID-19 More common with low flow nasal cannulas,
Intubation but can also occur with high flow systems
Extubation
General difficulty breathing Pneumothorax (collapsed lung).
There is a small risk of developing a collapsed
lung during treatment with a HFNC. In one
study, two children, 1% of the children in the
study, who received supplemental oxygen via
a nasal cannula developed a pneumothorax.
6. Identify nasal cannula, face masks, high flow masks
and self-inflating bag.
b) Face masks
Function: the face mask is use for the Fraction of O2 inspired (FiO2)
which will vary depending on the patient's inspiratory flow, mask fit/size
and patient's respiratory rate.
The minimum flow rate through any face mask is 4 LPM(litre per min) as
this prevents the possibility of CO2 accumulation and CO2 re-breathing.
Oxygen (via intact upper airway) via a simple face mask at flow rates of
4LPM does not routinely require humidification. However, as
compressed gas is drying and may damage the tracheal mucosa
humidification might be indicated/appropriate for patients with
increased/thickened secretions, secretion retention, or for generalized
discomfort and compliance. Additionally in some conditions (eg.
Asthma), the inhalation of dry gases can compound
bronchoconstriction.
6. Identify nasal cannula, face masks, high flow masks
and self-inflating bag.
c) High Flow Masks
It provides a high concentration of oxygen quickly, typically has
a flow rate of about 12 to 15 liters of oxygen per minute.
Main feature: It has several one-way valves that prevent the
patients from “rebreathing” any exhaled air or room air. They
are only inhaling oxygen directly from the reservoir bag and
oxygen tank, with no outside air diluting the oxygen.
Risk is when the oxygen tank empties, there’s no other source
of air, meaning you could suffocate in the mask.
The NRM allows a person to get 60% to 90% FIO2.
Indication:
usually for emergency use when a
person has low blood oxygen
levels, but can breathe on their
own. Some examples of
emergency situations would
include:
Smoke inhalation.
Carbon monoxide poisoning.
Trauma or other serious injury
to your lungs.
Cluster headaches.
Severe, chronic airway
disorders such as COPD or
cystic fibrosis.
Risk/Benefits
it delivers a high concentration of
oxygen quickly which helpful in
situations where a person needs extra
oxygen due to dangerously low blood
oxygen levels.
Disadvantage:
Can cause suffocation.
It doesn’t allow the patient to inhale
any outside air. They can only inhale
the air inside the oxygen tank.
When the oxygen tank empties, the
person wearing the non-rebreather
doesn’t get air.
A healthcare provider should watch
you closely when you’re using a non-
rebreather mask to make sure the
oxygen tank doesn’t empty.
6. Identify nasal cannula, face masks, high flow masks
and self-inflating bag.
d) Self-inflating bag.
Also known as bag valve and mask can be utilised to
manually ventilate an infant or child if their respiratory effort
is absent or inadequate.
They are use to provide oxygen during intermittent positive
pressure respiration (IPPR) via an endotracheal tube or a
facemask. They are used in emergencies when somebody is
facing breathing difficulties to provide artificial ventilation.
KEY POINTS
Can be use without oxygen. For example, if the child or infant deteriorated
during a transfer and you did not have access to oxygen.
When using with oxygen, at least 15L per minute of oxygen flow is required to
ensure adequate oxygen volume in the reservoir.
Paediatric self-inflating bags will have a pressure relief valve also known as a
‘pop-off’ valve. This valve prevents excess pressure being delivered to the
infant or child’s lungs, in turn reducing the risk of barotrauma. This valve
should always remain open (see ALERT on page 5), unless there is a need for
high pressure ventilation. This should be done by a senior medical officer or
under their direct guidance.
You will need to attach a correctly sized mask.
PEEP Valves can be attached to self-inflating bags and dialled up to a specific
pressure. They are used to provide positive end expiratory pressure (PEEP)
7. Assemble selected oxygen delivery systems

PROCEDURE (OXYGEN THERAPY)

1. Perform hand hygiene and don gloves. Don additional PPE based on the
patient’s need for isolation precautions or the risk of exposure to bodily fluids.
2. Verify the correct patient using two identifiers (name and date of birth)
3. Explain the procedure and ensure that the patient agrees to treatment.
4. Set up the oxygen delivery system.
5. Attach the oxygen flowmeter to the oxygen source.
6. Verify that the flowmeter is connected to oxygen, not air or another gas.
Connecting the flowmeter to a gas other than oxygen can have fatal
consequences.
7. Attach the humidifier to the oxygen flowmeter, if needed.
7. Assemble selected oxygen delivery systems
8. Attach the oxygen delivery device via the oxygen tubing to the humidifier or directly to
the oxygen flowmeter via the flowmeter adaptor.
9. Adjust the oxygen flowmeter to the prescribed flow rate.
10. Position the oxygen delivery device on the patient’s face and adjust the elastic
headband (or behind-ear loops and under-chin lanyard of the cannula) to achieve a
comfortably snug fit. Maintain enough slack on the oxygen tubing.

Nasal Cannula:
Select an appropriate-sized nasal cannula for the child, ensuring it is not too tight
or too loose.
Face Masks:
Hold the mask over the child's face, covering both the nose and mouth, ensuring
a good seal without excessive pressure.
7. Assemble selected oxygen delivery systems
High Flow Masks:
Gently insert the nasal cannula prongs into the child's nostrils or place the mask
securely over the child's nose and mouth.
Adjust the straps and fit to ensure comfort and a proper seal.
Connect the high flow system to the oxygen source and set the prescribed flow rate.

Self-Inflating Bag (Bag-Valve-Mask - BVM):

Ensure the one-way valve is properly connected to the mask to allow air to flow
from the bag to the patient's airway.
Connect the other end of the bag to an oxygen source or attach a reservoir if oxygen
enrichment is required.
Use proper technique, including providing controlled, gentle squeezes of the bag to
deliver breaths, and allowing for passive exhalation to prevent overinflation.
7. Assemble selected oxygen delivery systems
Non-rebreathing mask: Ensure that the mask is over the patient’s mouth and
nose, forming a tight seal. Also ensure that the reservoir bag remains partially
inflated on inspiration.

11. Verify that the oxygen delivery device is functioning properly.

12. Discard supplies, remove PPE, and perform hand hygiene.
13. Document the procedure in the patient’s record.

Youtube video: https://youtu.be/lo4UrRyvWC0?si=PHLh9nHsDiKNTRQG

8. Administer the appropriate oxygen delivery
system according to the simulated case
 Venturi mask

Simple mask
Head box

Partial rebreather
and
non-rebreather
mask
Carry out assessment of circulation
Assesment of circulation is done after the administration of rescue breaths
Circulation is assesed by observing the ‘Signs of life‘
Take no more than 10 seconds to asses signs of life
The signs of life to look out for are:

Movement Coughing/ Normal breathing Central pulse

The absence of signs of life indicate failure of circulation
Chest compressions should be started if within 10 seconds:
-There are no signs of life
-You cannot ascertain if there’s a pulse
-There’s a slow pulse (<60 bpm) with no signs of circulation
and no reaction to ventilation
Note: Unnecessary chest compressions are almost never damaging.
It’s important not to waste vital seconds before starting them
 9. Discuss on the clinical signs of shock
Definition of shock: condition wheretissues in the body don’t receive
enough oxygen and nutrients to allow the cells to function
Clinical signs of shock:
Low blood pressure
cold and clammy hands
hyperventilation
cyanosis
palpitations
low urine output
dehydration
10. Identify Hartmann’s solution, normal saline
and Ringer’s lactate solutions 1. Hartmann's solution:
Mild to moderate metabolic
acidosis associated with
dehydration or potassium
deficiency

2. Normal Saline:
Extracellular fluid replacement,
metabolic alkalosis in the
presence of fluid loss and mild
sodium depletion

3. Ringer's Lactate:
Aggressive volume
resuscitation from blood loss
or burn injuries and aggressive
fluid replacement in sepsis and
acute pancreatitis
 11. Calculate and administer fluid for
hypovolemic shock
Administer 20 mL/kg of fluid as a bolus over 5 to 10 minutes and repeat as needed.
If fluid boluses do not improve the signs of hypovolemic, hemorrhagic shock,
consider the administration of packed red blood cells without delay.

In many Paediatrics cases, a simple calculation called the 4-2-1 rule can determine
the hourly rate of fluid maintenance required for a child based on weight.

First 10 kg = 4 ml/kg per hour

Next 10-20 kg = 2 ml/kg per hour
Any remaining weight over 20 kg = 1 ml/kg per hour
12. Describe clinical signs of cardiopulmonary collapse

Cardiopulmonary collapse, also known as cardiac or respiratory arrest, is a critical medical emergency
that occurs when the heart stops beating or the lungs cease to function. This can result from various
underlying causes. Clinical signs of cardiopulmonary collapse include :

Altered consciousness
Absence of breathing or abnormal breathing
Absence of a palpable pulse
Cyanosis
Unresponsiveness
Pupillary changes
Loss of muscle tone
Incontinence
Decreased heart rate
Abnormal ECG or heart rhythm
13. Justify indications for CPR VD &NMR
- Combination of vasopressin and epinephrine during ACLS as
part of CPR
-When defibrillation and chest compressions have not
successfully restored circulation
- Vasopressin MOA : Constricts blood vessels (skeletal muscle,
bowel, fat tissue, skin) ---> Increase BP ---> Improve blood
flow to vital organs (brain)---> Increase coronary perfusion
pressure without without increase in myocardial oxygen
consumption ---> Support return of a pulse in cardiac arrest
situation
- Epinephrine MOA : Vasoconstrictive action ---> Rise in aortic
pressure ---> Increase coronary perfusion pressure
 - Non invasive mechanical ventilation is provision of
ventilatory support through patient’s upper airway using a
mask
- Patient experiencing respiratory failure but still has a
pulse
- In cases where CPR is prolonged more than few mins, and
hypoxia is cause of cardiac arrest, must ensure adequate O2
delivery to tissues.
- Bag valve Resuscitator (BV) and Mechanical Ventilator
(MV)
- Whenever advanced airway is inserted during CPR,
continuous compression with positive pressure ventilation
Bag Valve Resuscitator (PPV) should be delivered without pausing chest
compressions
14. Perform CPR

CPR on an infant (1 mnth - 1yrs)

https://youtu.be/n65HW1iJUuY?feature=shared

CPR on a child (1 - 12 yrs) :-

https://youtu.be/c7Q1s7ppSwc?feature=shared