Tennessee Pediatric Resuscitation Guide

Tennessee Pediatric Resuscitation Guide

Funding provided by the Tennessee Department of Health Bioterrorism Hospital Preparedness Program.

Reproduced with permission PALS Provider Manual, 2005. Algorithms ©2005, Copyright American Heart Association

Comprehensive Regional Pediatric Centers

Updated 01/08

Vanderbilt Children’s HospitalNashville, TN

T.C. Thompson Children’s HospitalChattanooga, TN

East Tennessee Children’s HospitalKnoxville, TN

Le Bonheur Children’s Medical CenterMemphis, TN

Access Center: 866-936-7811LifeFlight Comm: 800-288-8111

423-778-6101 ED

800-773-0129 ED865-541-8133 ED

901-287-6112 ED888-899-9355 TRANSPORT

2Updated 01/08

20 ml/kg of Normal Saline or Lactated Ringers

3Updated 01/08

Use for VF and pulseless VT

Use for unstable SVT and VTConsider use with stable SVT and VT after consultation with pediatric cardiologist

4Updated 01/08

10ml

IV/IO

IV/IO

IV/IO

IV/IO

IV/IO

IV/IO

IV/IO

5Updated 01/08

Insulin (Regular)

IV/IO

IV/IO

IV/IO

IV/IO or IM

IV/IO

IV/IO or IM

IV/IO

Status Epilepticus: 0.1 mg/kg IV/IO

6Updated 01/08

0.25 – 1gm/kg IV/IO over 20 - 30minutes

Status Asthmaticus: 1-2 mg/kg IV/IOloading dose

0.1 - 0.2 mg/kg IV/IO

Loading Dose: 15 - 20 mg/kg IV/IO

0.6 - 1.2 mg/kg IV/IO

Children: 1 - 1.5 mg/kg IV/IOInfants: 2 mg/kg IV/IO

2 - 4 mg/kg IV/IO

0.1 mg/kg IV/IO

7Updated 01/08

ECC Handbook p.76

ABCs: rapid head-to-toe assessment (refer back to p. 3 of this guide)

Give oxygen: hypoxia is # 1 cause of bradycardia in infants/children

Attach monitor /defibrillator

NO YES

Give oxygen If needed

Observe, reassess

Consider expert consult

Is bradycardia still causing symptoms?

Such as altered level of consciousness, respiratory distress, poor perfusion

Give oxygen

If HR < 60 with poor perfusion, start CPR

Consider atropine: IV/IO: 0.02 mg/kg may repeat minimum dose: 0.1mg max dose, child: 1mg

Consider cardiac pacing

Give epinephrine: IV/ IO: 0.01 mg/kg of 1:10 000 (0.1 mL/kg) ET: 0.1 mg/kg of 1:1000 (0.1 mL/kg)

Repeat every 3 to 5 minutes at same dose

Consider and treat possible causes: 6Hs and 5Ts Reference page 10

Bradycardia with a Pulse

8Updated 01/08

ECC Handbook p.77

ABCs: Give CPR Give oxygen as soon as available Attach monitor /defibrillator


Check rhythm: VF/ VTCheck pulse: none

Resume CPR until defibrillator is charged

Give 1 shock at 4 J/kg Resume CPR immediately


Repeat : every 3-5 min

Give 5 cycles of CPR



Give 1 shock at 4 J/kg Resume CPR immediately Consider:

-amiodarone 5 mg/kg IV or

- lidocaine 1 mg/kg IVor

-magnesium 25-50 mg/kg IV/IO if Torsade




Give 1 shock at 2 J/kg Resume CPR immediately Give 5 cycles of CPR

Pulseless Arrest – VF and Pulseless VT

9Updated 01/08

ECC Handbook p.77

.

Consider and Treat Possible Causes

6 Hs

5 Ts

Hypo xiaHypo volemia Hypo thermia Hypo glycemia Hypo / hyper kalemia Hydro gen ion (acidosis)

T amponadeT ension pneumothoraxT oxins – poisons, drugsT hrombosis – coronary (AMI) – pulmonary (PE)

T rauma

Check rhythm: Asystole/PEACheck pulse: none

Resume CPR immediately

Check rhythm: Asystole/PEACheck pulse: none

Resume CPR immediately


Repeat : every 3-5 min


ABCs: Give CPRGive oxygen as soon as available

Attach monitor /defibrillator

Pulseless Arrest – Asystole and PEA

10Updated 01/08

ECC Handbook p.78

Narrow QRS Wide QRS

If IV access is present:adenosine IV SLAM!

- first dose: 0.1 mg/kg - repeat dose: 0.2 mg/kg

or

Synchronized cardioversion: - first dose: 0.5 – 1J/kg - next dose: 2J/kg

Sedate before cardioversion but do not delay

Ventricular Tachycardia SVT

Infants: HR > 220 bpm

Children: HR > 180 bpm

History is vague, nonspecific HR does not vary

HR changes abruptly P waves absent or abnormal

Sinus Tachycardia

Infants: HR < 220 bpm

Children: HR < 180 bpm

History makes sense for HR HR variesP waves present and normal

Give oxygen

Consider vagal maneuvers but do not delay

Give oxygen if needed

Treat the cause

ABCs: rapid head-to-toe assessment

Give oxygen and support as needed

Attach monitor/defibrillator and identify rhythm

Synchronized cardioversion: - first dose: 0.5 – 1J/kg - next dose: 2J/kg

Sedate before cardioversion but do not delay

Expert consultation advised

Consider: -amiodarone 5 mg/kg IV over 30-60 min

or

-procainamide 15 mg/kg IV over 30-60 min


Tachycardia with Poor Perfusion

11Updated 01/08

ECC Handbook p.79

Narrow QRS Wide QRS

Obtain IV access

Give adenosine IV SLAM! - first dose: 0.1 mg/kg - repeat dose: 0.2 mg/kg

Consider: -amiodarone 5 mg/kg IV over 30-60 min

or

-procainamide 15 mg/kg IV over 30-60 min

or

-lidocaine 1 mg/kg IV bolus

Ventricular Tachycardia SVT

Infants: HR > 220 bpm

Children: HR > 180 bpm

History is vague, nonspecific HR does not vary

HR changes abruptly P waves absent or abnormal

Sinus Tachycardia

Infants: HR < 220 bpm

Children: HR < 180 bpm

History makes sense for HR HR variesP waves present and normal

Consult pediatric cardiologist

Consider synchronized cardioversion - first dose: 0.5 – 1J/kg - next dose: 2J/kg

Sedate before cardioversion

Obtain 12-lead ECG


Consider vagal maneuvers


Obtain IV access

ABCs: rapid head-to-toe assessment

Give oxygen

Attach monitor/defibrillator and identify rhythm


Treat the cause


Tachycardia with Adequate Perfusion

12Updated 01/08

Guidelines for Potassium Iodine (KI) Dose Administration

• Atropine 0.02-0.05 mg/kg IV/IO every 10-20 minutes until atropine effect (dry flushed skin, tachycardia, mydriasis, fever) is observed.

• Pralidoxime 20-50 mg/kg IV/IO or IM

• Diazepam 0.05-0.3 mg/kg (maximum dose: 10 mg) IV/IO or IM

• Lorazepam 0.1 mg/kg (maximum dose: 4 mg) IV/IO or IM

• Midazolam 0.1 mg-0.2mg/kg (maximum dose: 10 mg) IV/IO or IM

13Updated 01/08

14Updated 01/08

15Updated 01/08

Cat

egor

y A

– B

iolo

gica

l Age

nts

Age

nt

Incu

batio

n C

onta

giou

s &

Is

olat

ion

tnemtaer

T s

motpmyS

Post

Exp

osur

e Pr

ophy

laxi

s &

V

acci

natio

nA

nthr

ax

Inha

latio

nal

Cut

aneo

us

1-6

day

s N

o

Isol

atio

n P

reca

utio

nSt

anda

rd

Feve

r

Fat

igue

C

hills

C

ough

C

hest

pai

n

Follo

wed

by

Seve

re R

espi

rato

ry D

istr

ess

and

Shoc

k

Chi

ldre

n w

ith

inha

lati

onal

dx

may

hav

e “a

typi

cal”

pre

sent

atio

ns in

clud

ing

prim

ary

men

ingo

ence

phal

itis

.

Chi

ldre

n m

ay h

ave

an a

bnor

mal

ch

est

x-ra

y bu

t w

ith

othe

r fo

rms

of

ant

hrax

usu

ally

hav

e no

rmal

x-r

ay.

Papu

le, f

luid

-fill

ed v

esic

le, b

lack

esc

har

* C

hild

ren

Cip

ro 1

0-15

mg/

kg/d

ay I

V q

12

hrs

(not

to

exce

ed 1

g/d)

or

Dox

ycyc

line

2.2m

g/kg

IV

q 1

2 hr

s fo

r pa

tien

ts <

45k

g , a

dult

dos

e fo

r >

45

kg

Plu

s 1

or 2

oth

er a

ntib

ioti

cs (

incl

udin

g pe

nici

llin,

rif

ampi

n, c

linda

myc

in,

vanc

omyc

in, i

mip

enem

, and

ch

lora

mph

enic

ol)

* A

dult

Cip

ro 4

00m

g IV

BID

or

Dox

ycyc

line

200m

g IV

, the

n 10

0mg

IV

Bid

or

PC

N 4

mill

uni

ts I

V 4

hr

Cut

aneo

us s

ame

as I

nhal

atio

nal

Cip

ro 5

00m

g PO

bid

or

Dox

ycyc

lin 1

00m

g PO

bi

d in

con

juct

ion

with

va

ccin

e

Wom

en w

ho a

re o

r m

ight

be

pre

gnan

t sho

uld

use

Cip

rofl

oxac

in, o

r if

ot

herw

ise

cont

rain

dica

ted,

A

mox

icill

in 5

00m

g PO

tid

as

Dox

ycyc

line

may

ha

ve m

ore

pote

ntia

l for

ad

vers

e fe

tal a

nd m

ater

nal

effe

cts

Bot

ulis

m12

-72

hrs

No

Isol

atio

n P

reca

utio

nSt

anda

rd

Diz

zine

ss

Dry

mou

th a

nd th

roat

Dif

ficu

lt sp

eaki

ng o

r sw

allo

win

g

Blu

rred

vis

ion

Eve

ntua

l res

pira

tory

fai

lure

.

* C

hild

ren

Sam

e as

adu

lt r

egim

e:

Rev

erse

Tre

ndel

enbu

rg (

20-2

5°)

wit

h su

ppor

t of

cer

vica

l spi

ne f

or in

fant

s no

t on

a v

enti

lato

r.

* A

dult

One

via

l tri

vale

nt b

otul

ism

or

hept

aval

ent

a

ntito

xin,

mec

hani

cal v

entil

atio

n

Eve

ryon

e th

at is

kno

wn

or

susp

ecte

d of

hav

ing

been

ex

pose

d sh

ould

be

clos

ely

mon

itore

d an

d tr

eate

d w

ith a

ntito

xin

at th

e fi

rst

sign

of

dise

ase

Cat

egor

y A

– B

iolo

gica

l Age

nts

Age

nt

Incu

batio

n C

onta

giou

s &

Is

olat

ion

erusopxE tsoP

tnemtaer

T s

motpmyS

Prop

hyla

xis

&

Vac

cina

tion

Pne

umon

icP

lagu

e2-

3 da

ys

Yes

Isol

atio

n P

reca

utio

nSt

anda

rd

Dro

plet

Hea

dach

e

Hig

h fe

ver

G

ener

al w

eakn

ess

G

land

ular

sw

ellin

g Pa

infu

l bub

oes

Pn

eum

onia

Hem

orrh

ages

may

be p

rese

nt in

the

skin

an

d m

ucou

s m

embr

anes

Chi

ldre

n yo

unge

r th

an 1

y/o

are

mor

e su

scep

tibl

e to

men

ingi

tis,

cer

vica

l an

d/or

sub

max

illar

y bu

boes

*Chi

ldre

n St

rept

omyc

in 1

5 m

g/kg

/day

IM

q 1

2 hr

s (n

ot t

o ex

ceed

2/g

/day

)

or

Gen

tam

icin

2.5

mg/

kg I

V/I

M q

8 h

rs

(q 1

2 hr

s fo

r <1

wk

or p

rem

atur

e in

fant

s)

* A

dults

St

rept

omyc

in 1

g IM

q 1

2 hr

s (s

houl

d be

av

oide

d in

pre

gnan

t or

lact

atin

g w

omen

)

or

Gen

tam

icin

2m

g/kg

IV

/IM

load

dos

e th

en 1

-1.7

5mg/

kg I

V/I

M q

8 h

rs p

er r

enal

fu

nctio

n

*Chi

ldre

n D

oxyc

yclin

e 2.

2mg/

kg

for

pati

ents

, 45

kg o

r T

etra

cycl

ine

6.25

-12

.5m

g/kg

PO

qid

fo

r pa

tien

ts >

8 y

es o

r ci

prof

loxa

cin

20m

g/kg

P

D b

id –

MA

X 1

g/da

y

Adu

lts:

Dox

ycyc

lin 1

00m

g PO

bi

d or

Tet

racy

clin

e 25

0mg

Po q

id (

shou

ld b

e av

oide

d in

pre

gnan

t or

lact

atin

g w

oman

or

Cip

rofl

oxac

in

500m

g PO

bid

Smal

lpox

7-17

Day

s Y

es

Isol

atio

n P

reca

utio

nSt

anda

rd

Con

tact

A

irbo

rne

Hig

h fe

ver

Smal

l blis

ter

whi

ch d

evel

op in

to p

ustu

lar

vesi

cles

usu

ally

mor

e pr

eval

ent o

f th

e ex

trem

ities

and

fac

e

May

dev

elop

hem

orrh

ages

on

skin

and

m

ucou

s m

embr

anes

Supp

ortiv

e

Vac

cina

tion

reco

mm

ende

d w

ithin

3-5

day

s fo

r th

ose

expo

sed.

VIG

or

cido

fovi

r, a

n an

tivir

al d

rug

with

sub

stan

tial r

enal

toxi

city

, m

ay im

prov

e ou

tcom

es if

giv

en w

ithin

1-2

da

ys a

fter

exp

osur

e: h

owev

er th

ere

is n

o de

fini

tive

evid

ent t

o su

gges

t tha

t the

y ar

e be

tter

than

vac

cine

alo

ne.

Vac

cini

a im

mun

e gl

obul

in a

nd o

r va

ccin

e

Tul

arem

ia1-

21 d

ays

No

Isol

atio

n P

reca

utio

nSt

anda

rd

Feve

r, c

hills

Mal

aise

Hea

dach

e *C

hild

ren

Stre

ptom

ycin

15

mg/

kg/d

ay I

M q

12

hrs

(not

to

exce

ed 2

/g/d

ay)

or G

enta

mic

in 2

.5

mg/

kg I

V/I

M q

8 h

rs

* A

dults

St

rept

omyc

in 1

g IM

q 1

2 hr

s (s

houl

d be

av

oide

d in

pre

gnan

t or

lact

atin

g w

omen

) or

G

enta

mic

in 3

-5m

g/kg

IV

/IM

q d

ay

Dox

ycyc

line

100m

g PO

bi

d

or T

etra

cycl

ine

500m

g PO

qi

d

or C

ipro

flox

acin

500

mg

PO b

id

16Updated 01/08

Cat

egor

y A

– B

iolo

gica

l Age

nts

Age

nt

Incu

batio

n C

onta

giou

s &

Is

olat

ion

erusopxE tsoP

tnemtaer

T s

motpmyS

Prop

hyla

xis

&

Vac

cina

tion

Vir

alH

emor

rhag

ic

Feve

rs2-

21 d

ays

Yes

Isol

atio

n P

reca

utio

nSt

anda

rd

Con

tact

A

irbo

rne

Dro

plet

Hea

dach

e

F

ever

Chi

lls

Mal

aise

M

yalg

ia

Dia

rrhe

a be

gins

with

in 3

-5 d

ays

of

infe

ctio

n,

Ble

edin

g

Pet

echi

ae

H

ypot

ensi

on,

Shoc

k

CC

HF/

aren

avir

uses

: Rib

avir

in

Eve

ryon

e th

at is

kno

wn

or

susp

ecte

d of

hav

ing

been

ex

pose

d sh

ould

be

clos

ely

mon

itore

d an

d tr

eate

d w

ith a

rena

viru

ses

at th

e fi

rst s

ign

of d

isea

se

Isol

atio

n P

reca

utio

ns:

Sta

ndar

d: G

own,

glo

ves

and

if b

ody

flui

d sp

lash

or

spra

y po

ssib

le w

ear

eye

prot

ectio

n. W

ash

hand

s w

ith a

ntim

icro

bial

soa

p or

wat

erle

ss a

ntis

eptic

age

nt

Con

tact

: Sa

me

as S

tand

ard

Prec

autio

ns b

ut in

clud

es, p

riva

te r

oom

, lim

it pa

tient

mov

emen

t to

esse

ntia

l pur

pose

onl

y an

d us

e of

ded

icat

ed e

quip

men

t or

disi

nfec

t bet

wee

n pt

s

Dro

plet

: Sa

me

as S

tand

ard

Prec

autio

ns b

ut in

clud

es, p

riva

te r

oom

, sur

gica

l mas

k on

pat

ient

tran

spor

t and

lim

it m

ovem

ent t

o es

sent

ial p

urpo

ses

only

Air

bone

: Sa

me

as S

tand

ard

Prec

autio

ns b

ut in

clud

es, p

riva

te n

egat

ive

pres

sure

roo

m, N

95 r

espi

rato

r, s

urgi

cal m

ask

on p

t dur

ing

tran

spor

t, do

or c

lose

d at

all

times

FY

I:

If y

ou a

re N

OT

sur

e w

heth

er a

bio

terr

oism

rep

ort i

s tr

ue o

r no

t, ch

eck

with

cre

dibl

e so

urce

s su

ch a

s C

DC

’s H

ealth

-Rel

ated

Hoa

xes

and

Rum

ors

Web

site

at

http

://w

ww

.cdc

.gov

/hoa

x ru

mor

.htm

.

Ant

hrax

* T

rans

mis

sion

of

anth

rax

infe

ctio

n fr

om p

erso

n to

per

son

is u

nlik

ely.

*

Sym

ptom

s of

ant

hrax

and

the

flu

are

sim

ilar.

A r

unny

nos

e is

a r

are

sym

ptom

of

anth

rax.

A p

erso

n w

ho h

as a

run

ny n

ose

alon

g w

ith o

ther

com

mon

flu-

like

sym

ptom

s is

far

mor

e lik

ely

to h

ave

the

com

mon

col

d or

flu

than

to h

ave

anth

rax.

Smal

lpox

* W

hen

tran

spor

t is

nece

ssar

y, m

inim

ize

the

disp

ersa

l of

resp

irat

ory

drop

lets

by

plac

ing

a m

ask

on th

e pa

tient

. *

Vac

cina

tion

with

in 3

day

s of

exp

osur

e w

ill c

ompl

etel

y pr

even

t or

sign

ific

antly

red

uce

the

seve

rity

of

the

dise

ase

in th

e va

st m

ajor

ity o

f pe

ople

. *

Vac

cina

tion

4-7

days

aft

er e

xpos

ure

likel

y of

fers

som

e pr

otec

tion

from

dis

ease

or

may

mod

ify

the

seve

rity

of

dise

ase.

17Updated 01/08

Bla

st In

jury

Cat

ego

ries

Bla

st In

jury

Cat

ego

ries

•Bur

ns (f

lash

, par

tial a

nd fu

ll th

ickn

ess)

•Cru

sh in

jurie

s

•Clo

sed

and

open

bra

in in

jury

•Ast

hma,

CO

PD, o

r oth

er

brea

thin

g pr

oble

ms

from

dus

t, sm

oke,

toxi

c fu

mes

•Ang

ina,

hyp

erte

nsio

n

•Hyp

ergl

ycem

ia, o

ther

chr

onic

di

seas

es w

orse

ned

Any

body

par

t may

be

affe

cted

All e

xplo

sion

rela

ted

inju

ries

not

due

to 1

°, 2

°or

3°

mec

hani

sms

Qua

tern

ary

4°

•Fra

ctur

e an

d tra

umat

ic

ampu

tatio

n

•Clo

sed

and

open

bra

in in

jury

Any

body

par

t may

be

affe

cted

Res

ults

from

indi

vidu

als

bein

g th

row

n by

the

blas

t win

dT

ertia

ry

3°

•Pen

etra

ting

ballis

tic

(frag

men

tatio

n) o

r blu

nt in

jurie

s

•Eye

pen

etra

tion

(can

be

occu

lt)

Any

body

par

t may

be

affe

cted

Res

ults

from

flyi

ng d

ebris

and

bo

mb

fragm

ents

S

econ

dary

2°

•Bla

st lu

ng –

pulm

onar

y ba

rotra

uma

•TM

rupt

ure

and

mid

dle

ear

dam

age

•Abd

omin

al h

emor

rhag

e an

d pe

rfora

tion

•Glo

be (e

ye) r

uptu

re

•Con

cuss

ion

(TBI

with

out p

hysi

cal

sign

s of

hea

d in

jury

)

Gas

fille

d st

ruct

ures

are

mos

t su

scep

tible

–lu

ngs,

GI t

ract

, and

m

iddl

e ea

r

Uni

que

to H

E, re

sults

from

the

impa

ct o

f ove

r-pre

ssur

izat

ion

wav

e w

ith b

ody

surfa

ces

Prim

ary

1°

Type

of I

njur

ies

Body

Par

t Affe

cted

Cha

ract

eris

tics

Cat

egor

y

LE a

re c

lass

ified

diff

eren

tly b

ecau

se th

ey la

ck th

e se

lf-de

finin

g H

E ov

er-p

ress

uriz

atio

n w

ave.

LE’s

mec

hani

sms o

f in

jurie

s are

cha

ract

eriz

ed a

s due

to b

allis

tics

(fra

gmen

tatio

n), b

last

win

d (n

ot b

last

wav

e) a

nd th

erm

al fo

rces

. The

re is

som

e ov

erla

p be

twee

n LE

and

HE

2°, 3

°, a

nd 4

°.

18Updated 01/08

Tennessee Pediatric Resuscitation Guide

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Transcript of Tennessee Pediatric Resuscitation Guide