Paediatric and Neonatal Resus - · Web viewBP = (age x 2) + 85 UO = 2ml/kg/hr in infant,...
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Paediatric and Neonatal Resuscitation Epidemiology Most arrests are due to hypoxia, hypotension, acidosis, underlying illness; usually relieved by correction of A+B Most common dysrhythmias are severe bradycardia, asystole ; VF 7- 15%; ventricular arrhythmia Help first as likely cardiac if: witnessed collapses or known cardiac condition in child (and in all adults) BLS 1 st as likely respiratory if: unwitnessed arrest in child (not in adults) get help after 1min of CPR A: Turn on side if drowning; no finger sweep unless solid FB seen; Infant = neutral Child = sniff Measure guedel from centre of mouth to angle of mandible B: look, listen, feel 10 seconds 5x rescue breaths (?Now 2) in children (not adult) RR 10-12 (6-10 in adults) once ETT (every 15 compressions) C: ALS provider can do pulse check Site: Use brachial / femoral pulse if <1yr Paddle size: 4.5cm infant, 8cm child Shocks : All shocks 4J/kg Why?: start CPR if unresponsive / not breathing properly Start CPR if <60bpm with poor perfusion (absent in adults) How?: Pauses should be <10secs; Swap providers Q2min; Depth 1/3 AP diameter; lower ½ sternum; duty cycle 50%; 5 cycles / 2mins Use continuous ETCO 2 monitoring BVM size: round mask 000-2 for infants / young child; shaped mask 3-5 for young child / adult Bag size: 250ml bag in prem 500ml with pressure valve in neonate / infant 1500ml in young / older child ETT: mm: (age / 4) + 4 (uncuffed) + 3.5 (cuffed) Decrease size by 0.5mm if severe croup / epiglottitis Length: (age / 2) + 12 (or 15) LMA: <5kg =1; 5-10kg = 1.5; 10-20kg = 2; 20-30kg = 2.5; 30-50kg = 3; 50- 70kg = 4; 70-100kg = 5; >100kg = 6 Surgical: use cricothyroid puncture if <12yrs Ventilator: RR 20-30 (infant), RR 12-20 (child) B IV access: use IO if can’t get IVL in <90 secs if critically ill child Intraosseous: insert in antmedial proximal tibia 1 finger (2-3cm) beneath tibial tuberosity superior to medial malleolus anterolateral distal femur 3cm above lateral condyle Will not be able to aspirate from tibia if >5yrs due to fatty marrow; not reliable for PO 2 , PCO 2 , LFT; can do Hb, but not FBC; can do pH; same onset of drugs; can give up to 10- 15ml/min (125ml/min under C B: aim SaO 2 94-98% (PaO 2 60-80mmHg); aim normocarbia C: maintain adequate perfusion D: therapeutic hypothermia (32-34°) within 6hrs of cardiac arrest, and maintain up to 72hrs; Post-Resus Management Weight Newborn = 3.5kg 1 year = 10kg 1-10 years = (age+4) x2 >10 years = age x 3 BP = (age x 2) + 85 UO = 2ml/kg/hr in infant, 1ml/kg/hr in child Shock: 20ml/kg IV fluids if still shocked after 40ml/kg, use inotropes / blood products 4ml/kg PRBC increased Hb by 1 10ml/kg platekets increases platelets by 50 Fluids: avoid 5% dex (worsens neuro outcome, causes secondary diuresis; C DON’T FORGET GLUCOSE and TEMPERATURE!!! Epidemiology: required in 10% births; extensive resus in 1%; in >50% VLBW Causes: iNborn errors of metabolism, Electrolytes, OD, Seizures, Enteric, Cardiac, Recipe (formula etc…), Endocrine, Trauma, Sepsis Perinatal asphyxia: umbilical artery pH <7; 5min Apgar <4; neurological problems; multi- organ failure Fluid requirements in neonate: D1-2: 60-80ml/kg/day; D3-7: 100- 150ml/kg/day; D 8-28: 120- 180ml/kg/day Meconium aspiration: occurs in 12-20%, but aspiration rare; 25- Neonatal Life Support
Transcript of Paediatric and Neonatal Resus - · Web viewBP = (age x 2) + 85 UO = 2ml/kg/hr in infant,...
Paediatric and Neonatal Resuscitation
Epidemiology
Most arrests are due to hypoxia, hypotension, acidosis, underlying illness; usually relieved by correction of A+BMost common dysrhythmias are severe bradycardia, asystole; VF 7-15%; ventricular arrhythmia more common if cardiac disease, poisoning, low voltage electrocution; SVT may cause shock 5-10% neonate require resus; 1% require intensive resus
Help first as likely cardiac if: witnessed collapses or known cardiac condition in child (and in all adults)BLS 1st as likely respiratory if: unwitnessed arrest in child (not in adults) get help after 1min of CPR
A: Turn on side if drowning; no finger sweep unless solid FB seen; Infant = neutral Child = sniff Measure guedel from centre of mouth to angle of mandible
B: look, listen, feel 10 seconds 5x rescue breaths (?Now 2) in children (not adult) RR 10-12 (6-10 in adults) once ETT (every 15 compressions)
C: ALS provider can do pulse check Site: Use brachial / femoral pulse if <1yr Paddle size: 4.5cm infant, 8cm child Shocks: All shocks 4J/kg Why?: start CPR if unresponsive / not breathing properly Start CPR if <60bpm with poor perfusion (absent in adults) How?: Pauses should be <10secs; Swap providers Q2min; Depth 1/3 AP diameter; lower ½ sternum; duty cycle 50%; 5 cycles / 2mins Rate: 100-120/min (100 in adults) Ratio: 3:1 in neonate 15:2 in children (30:2 if layperson or 1 person) 30:2 in adult at all times Rhythm check: Q2min Chest compressions: infant = 2 fingers <8yrs = 1 hand >8yrs and adults = 2 hands
Use continuous ETCO2 monitoringBVM size: round mask 000-2 for infants / young child; shaped mask 3-5 for young child / adultBag size: 250ml bag in prem 500ml with pressure valve in neonate / infant 1500ml in young / older childETT: mm: (age / 4) + 4 (uncuffed) + 3.5 (cuffed) Decrease size by 0.5mm if severe croup / epiglottitis Length: (age / 2) + 12 (or 15)LMA: <5kg =1; 5-10kg = 1.5; 10-20kg = 2; 20-30kg = 2.5; 30-50kg = 3; 50-70kg = 4; 70-100kg = 5; >100kg = 6Surgical: use cricothyroid puncture if <12yrsVentilator: RR 20-30 (infant), RR 12-20 (child) PEEP 3-5 TV 7-10ml/kg I:E 1:2 PIP 15 (neonate), 25 (RDS), 20-25 (child) FiO2 100% initially Have small air leak NG mandatoryIntercostal catheter: neonate 8-12F Infant 14-20F Child 20-28F Adolescent 28-36F 4x ETT sizeCricothyroidotomy cannula: adults 6mm, child 4mm, baby 3.5mm
B
IV access: use IO if can’t get IVL in <90 secs if critically ill childIntraosseous: insert in antmedial proximal tibia 1 finger (2-3cm) beneath tibial tuberosity superior to medial malleolus anterolateral distal femur 3cm above lateral condyleWill not be able to aspirate from tibia if >5yrs due to fatty marrow; not reliable for PO2, PCO2, LFT; can do Hb, but not FBC; can do pH; same onset of drugs; can give up to 10-15ml/min (125ml/min under pressure); flush all drugs with 10ml N salineContraindications = osteoporosis, osteogenesis imperfecta, fracture, recent same bone intraosseous, cellulitis, burns; complications rare (<1%; tibial #, growth retardation, compartment syndrome, cellulitis, osteomyelitis, extravasation of fluid)C
B: aim SaO2 94-98% (PaO2 60-80mmHg); aim normocarbiaC: maintain adequate perfusionD: therapeutic hypothermia (32-34°) within 6hrs of cardiac arrest, and maintain up to 72hrs; avoid hypo/hyperglycaemia
Post-Resus Management
Weight Newborn = 3.5kg 1 year = 10kg 1-10 years = (age+4) x2 >10 years = age x 3
BP = (age x 2) + 85 UO = 2ml/kg/hr in infant, 1ml/kg/hr in childShock: 20ml/kg IV fluids if still shocked after 40ml/kg, use inotropes / blood products 4ml/kg PRBC increased Hb by 1 10ml/kg platekets increases platelets by 50 Fluids: avoid 5% dex (worsens neuro outcome, causes secondary diuresis; hypoNa) Maintenance: use 0.45% saline + 2.5-5% dex in children Use 0.18% saline + 10% dex in neonates Shocks: unstable SVT: 0.5-1J/kg; pulsatile VT 0.5-2J/kg
C
DON’T FORGET GLUCOSE and TEMPERATURE!!!
Epidemiology: required in 10% births; extensive resus in 1%; in >50% VLBWCauses: iNborn errors of metabolism, Electrolytes, OD, Seizures, Enteric, Cardiac, Recipe (formula etc…), Endocrine, Trauma, SepsisPerinatal asphyxia: umbilical artery pH <7; 5min Apgar <4; neurological problems; multi- organ failureFluid requirements in neonate: D1-2: 60-80ml/kg/day; D3-7: 100-150ml/kg/day; D 8-28: 120- 180ml/kg/dayMeconium aspiration: occurs in 12-20%, but aspiration rare; 25-50% require mechanical ventilation; 5% die; due to in utero fetal distress; if stained, suction as soon as head delivered Do laryngoscopy and tracheal suction through ETT if: meconium staining + not vigorous (decreased RR/tone, HR <100); repeat until no further meconium withdrawn; if still severely depressed after meconium cleared, start active resus
Neonatal Life Support
Adrenaline: 10mcg/kg IV/IO (= 0.1ml/kg 1:10,000) 100mcg/kg ETT (= 0.1ml/kg 1:1000) Give after 2nd shock then every 2nd cycleAmiodarone: 5mg/kg after 3rd shock repeat dose after 5th shockAtropine: 0.02mg/kg (max 600mcg) IVAdenosine: 50mcg/kg 100mcg/kg 240mcg/kg (max 12mg)Sux: 3mg/kg (neonate) 2mg/kg (child) 1.5mg/kg (adult)Vec: 0.1mg/kgDiazepam: 0.25mg/kg IVMidaz: 0.15mg/kg IVDextrose: 2-5ml/kg 10% dexHCO3: 1mmol/kg if pH <7.1Naloxone: 0.1mg/kg IM/IV (give if maternal opiates <4hrs and resp depression after IPPV has restored normal HR and colour; CI if maternal narcotic addiction)Calcium: only if hyperK/Mg, hypoCa, Ca channel blocker OD
Drugs and Doses
Stimulate, dry, warm (if premature, may need plastic bag)A: open airway, suction mouth and nose; do Apgar after thisB: O2 if SaO2 <95%
Indications for IPPV via BVM: Apnoea for 30secs / gaspingHR <100Persistent central cyanosis despite 100% O2
Apgar 4-7Use RR 30-40; give for 30-60secs; p 20mmHg (may need inflation p 30-35mmHg briefly, 20- 25mmHg in prems)
Indications for considering ETT: Not improving after 30sec IPPV Apgar <4Prolonged resus (ie. Need for chest compressions)PrematureMeconium aspiration?congenital diaphragmatic herniaVLBWMay need higher airway p and PEEP in prems
C: Indications for chest compressionsHR <60 after 30secs ventilatory supportUse 3:1; 1/3 depth of chest; lower ½ sternum, 100/min, will have RR 30
Effective cough: coughIneffective cough: unconscious CPR, direct laryngoscopy ASAP Conscious 5x back blows 5x chest thrusts (alternate with abdo thrusts in children) Finger sweep if visible material
Foreign Body Aspiration
Effective cough: coughIneffective cough: unconscious CPR, direct laryngoscopy ASAP Conscious 5x back blows 5x chest thrusts (alternate with abdo thrusts in children) Finger sweep if visible material
Foreign Body Aspiration
Outcomes from resus worse than in adults; 9% survival to discharge (<10% intact survival rate); if arrive to ED pulseless, death in 95%, all survivors have poor neuro outcomeIf CPR continued for 30mins with no ROSC, then continued resus is futile (may continue longer if arrest was witnessed and CPR immediately)
Prognosis
