P A L S U P D A T E What's New - Pediatric BLS & PALS Guidelines: Overview of 2010 International Guidelines

Waseem Hafeez, MD - The Childrens Hospital at Montefiore

CPR sequence changed: C-A-B rather than A-B-C (single provider sequence except newborn) Initiation of CPR with chest compressions rather than rescue breaths leads to a shorter delay to 1

st compression - leads to improved outcome.

EMS activation: CPR first vs. Call first CPR FIRST appropriate for most infants and children because respiratory problems more likely CALL FIRST = AED: witnessed sudden collapse in victims of any age (esp. h/o cardiac disease, tca/digoxin OD)

De-emphasis of pulse check for healthcare providers: For a child who is unresponsive and not breathing, if a pulse cannot be detected within 10 seconds, begin CPR immediately, starting with chest compressions.

Chest compression@ rate 100/min: Infants - just below nipple line; Age >1 yr - centrally between the nipples Depth of compressions: at least one third of the anterior-posterior diameter of the chest; this corresponds to approximately

1.5 inches (about 4 cm) in most infants and about 2 inches (5 cm) in most children and adolescents.

After delivery of 30 chest compressions, the lone rescuer opens the victims airway and delivers 2 breaths. Removal of look, listen, and feel for breathing from the sequence Compression - Ventilation ratio: Provide 5 cycles in 2 min - (see Table 1) 1 rescuer: All ages = 30:2 ratio provides more compressions/minute and higher coronary artery perfusion pressure 2 rescuer: Infants and children < 8 yrs old = 15:2 ratio provides more ventilations/min appropriate for hypoxic arrest Newly born: 3:1 ratio = 120 events/min ( 90 compressions + 30 breaths per minute)

Airway: Open and maintain the airway with a Chin lift and Head Tilt. Trauma: Jaw thrust - if it does not open the airway, protect C-spine and use Head tiltChin lift

Bag-mask ventilation (BVM): bag size = neonatal-infant 450 - 500ml / child-adult 1 2 L; Oxygen flow 10 - 15 L/min ET tube: Primary confirmation includes exam, pulse oximeter and exhaled CO2 detector or capnography PETCO2 value Cuffed tubes may be used in any age if pressure < 20 cm H2O

Laryngeal Mask Airway (LMA) may be used by advanced providers only if ineffective BVM and/or failed ETT The routine use of cricoid pressure in cardiac arrest is not recommended. Early Intraosseous (IO) use in all ages if access not available in < 90 sec ( Jamshedi IO, EZIO, BIG gun, FAST1) Automatic External Defibrillator(AED) recommended for witnessed sudden collapse /cardiac arrest. Children 1 to 8 years use a pediatric dose-attenuator system if one is available; Infants (0.09 sec (detected by computer EKG) Amiodarone, Procainamide & Lidocaine recommended, Magnesium Sulfate for Torsades de Pointes only Lidocaine de-emphasized, but can be used if Amiodarone is not available, not effective or contraindicated VT with pulse Stable: Amiodarone IV infusion / Unstable: immediate Synchronized Cardioversion Defibrillation dose: One shock (2J/kg) followed by immediate CPR (beginning with chest compressions) Sequence: CPR (stop only to deliver shock) Defib (2J/kg) CPR Defib (4J/kg) Drug CPR Defib (4J/kg) Adenosine recommended for initial management of undifferentiated regular monomorphic wide-complex tachycardia (should not be used for irregular wide-complex tachycardias because it may cause degeneration of the rhythm to VF). Identify & treat cause: 5 Hs and Ps (see Dysrhythmia Algorithm )

Post-resuscitation interventions: Maintain normal ventilation avoid hyperventilation New recommendation: once spontaneous circulation has been restored, maintain an arterial oxyhemoglobin saturation >94% to 99% to limit the risk of hyperoxemia Temperature control avoid hyperthermia and hypothermia during resuscitation Etomidate not used as part of RSI in Septic Shock adrenal suppression Therapeutic Hypothermia - (32C to 34C) may be beneficial for comatose adolescents after resuscitation from sudden witnessed out-of-hospital VF cardiac arrest; and >36wk GA infants after resuscitation from cardiac arrest. Monitor glucose avoid hyperglycemia Inotropes use dopamine, dobutamine, epinephrine, norepinephrine, amrinone, milrinone

Neonatal Resuscitation in ED: (See Neonatal Resuscitation Algorithm) A-B-C sequence maintained with 3:1 compression-ventilation ratio = 120 events/min (90compressions + 30breaths/min) Blood oxygen levels in uncompromised babies generally do not reach extrauterine values until approx 10 mins following

birth. Skin color is poor indicator of oxyhemoglobin saturation during immediate neonatal period. Initiate resuscitation with air or blended oxygen, titrating the oxygen concentration to an SpO2 in the target range (see

Neonatal algorithm) using pulse oximetry with the probe attached to the right upper extremity (i.e., wrist or palm). If the baby is bradycardic (HR

PEDIATRIC DYSRYTHMIA ALGORITHM Waseem Hafeez, MD

1. Assess Patient & Check Pulse

2. Analyze Rate 1

3. Rhythm: P-wave / QRS

4. Treat Patient 2 2 3 3 2

2 3 3 3 3

3

3wh Update 10/2014

CHECK PULSE PRESENT ABSENT

CHECK RATE

HR < 60 bpm

UNSTABLE

Check ABCs 100% O2 Monitor Evaluate

Initiate CPR Epinephrine (1:10,000)

0.1 ml/kg IV q 3-5 min Vagal/Primary AV block: Atropine (0.02 mg/kg) min 0.1 mg

max 0.5 mg child

1 mg adolescent

Consider Pacing

CHECK QRS

NARROW QRS < 0.09

WIDE

QRS >0.09

CHECK P-WAVE

NORMAL

PROBABLE SINUS TACHYCARDIA Infant 220 bpm;child >180 bpm)

STABLE:

Check ABCs Give 100% O2 IV access Vagal stimulation (no delay) Adenosine: rapid push / large IV + 5-10 ml NS flush First dose 0.1 mg/kg IV push (6 mg maximum)

repeat dose 0.2 mg/kg IV push (12 mg maximum)

Consider Synchronized Cardioversion UNSTABLE:

Cardioversion 0.5 1 J/kg (max: Mono 100, 200, 300, 360J / Biphasic 100, 200J)

PULSELESS VENTRICULAR TACH - FIBRILLATION Continue CPR (while defibrillator charges) Defibrillate X 1 2 J/kg (max 200J mono / biphasic) Defibrillate 4 J/kg (max: Mono 360 J/ Biphasic 200 J) Epinephrine: (1:10,000) 0.1 ml/kg IV q 3 - 5 min Amiodarone 5 mg/kg(max 300 mg) IV bolus shock 4 J/kg or Lidocaine 1 mg/kg (max 100 mg) IV bolus shock 4 J/kg Torsades : Magnesium 25 - 50 mg/kg (2 G max) Repeat sequence: CPR 2 min shock 4 J/kg drug CPR

UNSTABLE SIGNS

Altered mental status Hypotension

s/s Shock, Resp failure

CPR (5 cycles in 2min)

8yr: 30 compressions

+ 2 breaths

4wh Update 10/2014

Warm Shock:

Norepinephrine Cold Shock:

Epinephrine

Septic Shock:

* Fluid refractory & Dopamine

or Norepinephrine - dependent

shock defines patient risk for

adrenal insufficiency.

Draw baseline cortisol; consider ACTH stimulation test

if unsure of need for steroid

If Adrenal insufficiency is

suspected:

Hydrocortisone 2mg/kg IV bolus (Max 100mg)

P A L S P E A R L S Waseem Hafeez, MD

Childrens Emergency Services, CHAM

1. Assess Response: Unresponsive/No pulse palpated within 10 sec/ No Breathing or No Normal Breathing (only gasping)

Appearance (well appearing / ill appearing / lethargic), Activity, Age-appropriate response A Airway with C-Spine control:

Clear

Maintainable : Non-invasive - 100 % Oxygen, Head Tilt - Chin Lift, Jaw Thrust (trauma), Suction

Unmaintainable : Intervention - Bag Valve Mask, Intubation, LMA, Cricothyrotomy

B Breathing: (RACE) Initial 2 Rescue breaths (1 breath/second) then 10-20 breaths/min Respiratory Rate (average): NB = 60

1 yr = 50

3 yrs = 40

5 yrs = 30

8 yrs = 25

10 yrs = 20

>15 yrs = 16

Air Entry Breath sounds in all areas, Wheezing, Rales Color Pink, Pallor, Cyanosis, Mottled

Effort / Mechanics Nasal flaring, Grunting, Head bobbing, Accessory muscle use, Stridor Retractions Suprasternal / Subcostal / Intercostal

C Circulation: Pulse check (4 Ps) Chest Compressions @100/min - 30C : 2B (2 rescuer < 8yrs = 15C : 2B)

In Shock: Establish 2 large-bore vascular access (Think IO!!)

Pulse Rate (average): NB = 160 8 yrs = 110

1 mo = 150 10 yrs = 100

6 mo = 140 12 yrs = 90

1 yr = 130 15 yrs = 80

3 yrs = 120 >15 yrs = 60

Pulses (Central / Peripheral) Femoral, Brachial, Carotid / Dorsalis pedis, Radial Pressure Blood Pressure: Age: NB 1 mo = Systolic [ 5th %tile] : 60 mm Hg

1 mo 1 yr = Systolic [ 5th %tile] : 70 mm Hg 1 yr 10 yr = Systolic [ 5th %tile] : 70 mm Hg + ( 2 x Age )

10 yr = Systolic [ 5th %tile] : 90 mm Hg Diastolic = 2/3rd Systolic BP

Perfusion - End organ perfusion (Systemic Circulation):

Skin Perfusion Cap refill, Color, Temperature Renal Perfusion Urinary Output @ 1 2 ml/kg/hr upto 50 ml/hr CNS perfusion Level of consciousness: AVPU Response:

(A= Awake; V= Responds to Voice; P= Responds to Pain; U= Unresponsive)

D Dextrose (Bedside Fingerstick) / Disability - Neurologic status: Pupils, AVPU, GCS E Exposure / Etiology F Foley / Fever control G Gastric tube (NG / Orogastric) / Guiaic / Gases H Hct / History (SAMPLE Signs & Symptoms, Allergy, Medications, PMH, Last meal time, Environment)

2. Preparation: IMSOAPP = I IV Fluids / IV Catheter / IO - Intraosseous needle M Monitors: Cardiac; Pulse Oximeter; Blood Pressure (Dynamap) S Suction: Yankauer & flexible catheters O 100 % Oxygen source A Airway equipment: BVM, Laryngoscope & ETT, Oral & NP airway P Pharmacy (code meds) Personnel (Call a Code: have team available)

3. Weight Estimation: Wt (kg) = 2 X (Age in Years + 4)

4. Laryngoscope Blade: MiLler [L-shaped] Age Size

MaCintosh [C-shaped] 0 0 [L]

1 1 [L]

2 8 2 [L] > 8 Adol 3 [L/C]

5wh Pearls 10/2014

5. ET Tube size: All ages: Uncuffed = (16 + Age) = 4 + Age Cuffed = 3.5 + Age

4 4 4 Premature = Gestational Age in wks

10 6. ET Tube depth: Alveolar ridge to mid-trachea = 3 x ETT size or (12 + Age)

2

7. Complications of Intubation : DOPE = D Dislodge /Displaced into Esophagus O Obstructed: Secretions, Kinked, Right mainstem P Pneumothorax E Equipment air leak(small tube) / check Oxygen source / inadequate TV- small Bag, shallow breaths , Pop off valve

8. Medications through ETT: LEAN {Lidocaine, Epi, Atropine, Narcan}

9. End tidal CO2 monitor: Gold - is Good ; Purple - is Problem ( Pull it out)

10. Airway Size: Oral Airway: Unconscious = corner of mouth to angle of jaw

NP Airway: Conscious = tip of nose to tragus of ear

11. Tube Size: Suction / NG tube / Foley sizes = 2 X ETT size Chest tube size = 4 X ETT size

12. Tubes and fingers in every orifice: ET tube, NG tube, Foley, Rectal exam: guiaic / tone

13. Medication Dose: Rule of Ones {all peds code medication doses related to 1}

14. Epi doses = 0.1 ml / Kg - IV/IO & Neonatal dose @ 1:10,000; ETT dose @ 1:1,000

15. Shock: Medical- Fluids NS @ 20 ml/kg x 3 = 20 40 60 cc/kg (total) Panic ( Pressor )

Trauma- Fluids NS @ 20ml/kg X 2=2040ml/kg(total)Panic (PRBC:cross matched /Type specific/female -O neg /male- O pos)

16. Shock & Pressors: Hypovolemic Fluids NS bolus@ 20 - 60 ml/kg Dopamine

Distributive Fluids NS bolus @ 20 - 60 ml/kg NorEpinephrine / Epinephrine

Cardiogenic Fluids NS bolus @ 5-10 ml/kg Dobutamine / Milrinone 17. Preparation of Drips: (Premixed Solutions available)

Alprostadil: Dose = 0.05 - 0.1 mcg/kg/min ( Mix 0.25 mg in 50 mL D5W)

Amiadarone: Dose = 5 mg/kg ( Mix 360 mg in 200 ml D5W )

Dopamine: Dose = 2 - 20 mcg/kg/min ( Mix 400 mg in 250 ml D5W )

Dobutamine: Dose = 2 - 20 mcg/kg/min ( Mix 500 mg in 250 ml D5W )

Epinephrine / NorEpi Dose = 0.05 - 2 mcg/kg/min (Epi = Mix 1 mg in 50 ml D5W) / (NorEpi = Mix 1.6 mg in 50 ml D5W)

Lidocaine: Dose = 20 - 50 mcg/kg/min ( Mix1000 mg in 250 ml D5W )

Nicardipine: Dose = 0.5 - 5 mcg/kg/min ( Mix 25 mg in 50 mL NS or D5W )

Vasopressin: Dose = 0.5- 1.5 milliUnit/kg/min ( Mix 20 Units in 200 ml D5W )

18. V Fib Algorithm: CPR - Shock(2J/Kg) - CPR - Shock(4J/Kg) - Everybody-Shock(4J/kg) - Adult-Shock(4J/kg) - Little-Shock(4J/kg)

Defibrilate Epinephrine Amiodarone Lidocaine

Sequence: CPR (stop only to deliver shock) Defib (2J/kg) CPR Defib (4J/kg) Drug CPR Defib (4J/kg) 19. Causes of Arrest:

5 Hs = Hypovolemia, Hypoxemia, Hypoglycemia, Hypo / Hyperthermia, Hypo / Hyperkalemia 5 Ps = Pneumothorax (Tension ), Pericardial tamponade, PE, Poisons (toxic OD), pH (severe acidosis)

20. Rapid Sequence Intubation (RSI): 10 Ps Preparation / Pre-sedation assessment / Pre-Oxygenation / Pre-Medication / Priming-defasiculation /

Pain control(sedation) / Pressure (cricoid) /Paralysis / Place tube (Intubate) / Post-Intubation Analgesia & Paralysis

21. Newborn Resuscitation:

Functional History: 4 Ms = Maturity (FT-PT) / Multiple Gestation / Meconium / Meds (Narcotics within 4 hours) Temp, A, B, C, Drugs: Dry, Warm, Position, Suction, Stimulate

(HR

NEONATAL RESUSCITATION ALGORITHM Waseem Hafeez, MD

Approximate time

YES Keep with Mom

NO

YES 30 sec

NO NO YES

30 sec NO

YES NO YES

30 sec NO YES

HR < 60

HR < 60

7wh Pearls 10/2014

BIRTH

CHEST COMPRESSIONS

@ 90/min + 30V (CV ratio 3:1)

POSITIVE PRESSURE VENTILATION Bag Valve Mask Or Endotracheal Intubation Oxygen 100% @ 40 60 breaths/min Or Room Air if no improvement in 90sec SpO2 monitoring

Suction Trachea

Supportive Care

Monitor- HR, RR, SpO2

MECONIUM ?

MEDICATION - Epinephrine IV = 0.1 ml / kg (1:10,000) q 3-5 min ETT = 1 ml / kg (1:10,000)

POST- RESUSCITATION CARE Hypothermia warmth Hypovolemia 10 ml/kg NS; O-ve Blood Hypoglycemia 0.5-1 G/kg D10W Acidosis 1meq/kg Na Bicarb 4.2% Therapeutic Hypothermia (33.5-34.5C) within 6hrs of birth

>36 wk GA with hypoxic-ischemic encephalopathy

FUNCTIONAL HISTORY(4 Ms) Maturity Gestation age Multiplicity single or more Meconium color of fluid Medication Opioid use in 4 hrs

INITIAL ASSESSMENT Term Gestation ? Breathing or Crying ? Heart rate > 100 ? Good muscle tone ?

SUPPORTIVE CARE Provide warmth Position Clear airway (suction) Dry, Stimulate

MECONIUM with: Absent or depressed respirations Heart rate < 100 bpm Poor muscle tone

SUPPORTIVE CARE Provide warmth Position, Clear airway (suction) Dry, Stimulate Monitor- HR, RR, SpO2

RE- EVALUATE Heart rate < 100 ? Gasping or Apnea ? SpO2 below target range ?

Labored Breathing ?

Persistence Cyanosis ?

Clear airway SpO2 monitoring Consider CPAP

Targeted Preductal

SpO2 After Birth 1 min 60 65% 2 min 65 70% 3 min 70 75% 4 min 75 80% 5 min 80 85% 10 min 85 95%

IMPROVED ?

Adapted from AHA 2010 Guidelines