Pediatric Resuscitation & Emergencies Flashcards
Oxygen
Ventilate w/ 100% FiO2
Epinephrine
Hypotension 1mcg/kg
Cardiac arrest 10mcg/kg repeat Q3-5min as needed
Atropine
Symptomatic bradycardia 0.02mg/kg or 20mcg/kg
Max dose 1mg (child) or 2mg (adolescent)
Adenosine
100mcg/kg rapid IV bolus & flush
Max 6mg
Double 2nd dose 200mcg/kg
Max 12mg
Amiodarone
5mg/kg IV
Max 300mg
Vfib or Vtach
Lidocaine
1mg/kg IV followed by 20-50mcg/kg/min on the infusion pump
Magnesium
25-50mg/kg IV
Max 2g
Torsades de pointes
Bicarbonate
1-2mEq/kg IV based on ABG results
Calcium Chloride
CENTRAL
10-20mg/kg IV (0.1-0.2mL/kg 10% solution)
Calcium Gluconate
Peripheral
30-60mg/kg IV (0.3-0.6mL/kg 10%)
Procainamide
5-15mg/kg IV loading dose over 30-60min then 20-80mcg/kg/min on the infusion pump
EKG monitoring required
Caution: Monitor for hypotension or prolonged QT
Cardiac Arrest Risk Factors
Cardiac surgery Infants < 1mos old ASA > 3 Prematurity Congenital heart disease (aortic stenosis, cardiomyopathy, single ventricle) Emergency procedures
Medication-Related Cardiac Arrest Etiologies
Anesthetic overdose Succinylcholine Neostigmine induced Medication error/swap Drug reactions Inadvertent IV local anesthetic injection LAST High spinal Inadequate paralytic reversal Opioid-induced respiratory depression
Cardiovascular Causes
Hypovolemia Hemorrhage Inadequate volume administration Hyperkalemia Hypocalcemia Hypoglycemia Vagal Central line → dysrhythmias, hemorrhage, tamponade Embolism (air, clot, fat) Malignant hyperthermia Hypothermia Myocardial infarction Sepsis Adrenal insufficiency
Respiratory Causes
Inadequate oxygenation/ventilation
Inability to ventilate i.e. laryngospasm, bronchospasm, or mediastinal mass
ETT misplacement, kink, plug, or accidental extubation
Difficult airway anatomy
Residual neuromuscular blocker
Aspiration
Pneumothorax
ROSC
Return of spontaneous circulation
Restoration a perfusing rhythm & BP that persists at least 20min post arrest
Asystole
Outside Hospital
Associated w/ poor ROSC & survival
Often d/t prolonged hypoxia & represents terminal rhythm
Asystole
OR
Initial rhythm response to vagal stimulation
More likely to reverse & associated w/ good prognosis
Examples: Insufflation or carotid massage
Prolonged Arrest
Lengthy low-flow intervals, inadequate perfusion, myocardial and cerebral injury
What timeframe predicts mortality?
CPR > 15min
How many CPR hours have been reported in anesthesia-related events w/ good outcome?
3 hours
When to activate ECMO?
After 10min failed resuscitation w/ reversible conditions
Periop Cardiopulmonary Arrest
- Inhalational induction 25% (laryngospasm, agent overdose, depressed myocardial function)
- Craniofacial or spine surgery d/t hypovolemia, blood loss, or VAE
- Hyperkalemia d/t rapid RBC transfusion
- VP shunt malfunction ↑ICP
- LAST
- Anaphylaxis
LAST Treatment
IV 20% lipid emulsion 1.5mL/kg over 1min
Followed by 0.25mL/kg/min infusion over 10min
Cardiopulmonary Resuscitation
- Recognize need CPR
- Know how to correctly perform (oxygenation, ventilation, circulation, defibrillation/cardioversion)
- Vascular access
- Medications
- Teamwork
- Documentation
- Post-resuscitation care
- Self-care post critical incident
When to begin chest compressions?
HR < 60bpm
Children are HR dependent
Newborn Pulse Check
Umbilicus
EKG
Brachial
Infant Pulse Check
Brachial or femoral artery
Child Pulse Check
Carotid or femoral
Other considerations during pediatric emergency include:
100% FiO2
Discontinue all anesthetics
Newborn BLS
Compressions 90/min 1/3 chest anterior-posterior diameter 2 encircling thumbs Lower 1/3 sternum Breaths 30/min
Infant BLS
Compressions 100-120/min 1/3 chest AP diameter (4cm) 2 encircling thumbs Lower 1/3 sternum Breaths 10/min
Child BLS
Compressions 100-120/min 1/3 chest AP diameter (5cm) 1 or 2 hands Lower 1/3 sternum Breaths 10/min
Adolescent BLS
Compressions 100-120/min Depth 5-6cm 2 hands Lower 1/2 sternum Breaths 10/min
When to intubate?
Recommended during CPR in the OR Ensure adequate ventilation ↓aspiration risk Minimal interruptions to compressions w/ trained anesthesia providers Check correct placement
ETT Medications
Lidocaine Epinephrine Atropine Naloxone Surfactant Albuterol Vasopressin Diazepam (Valium)
Defibrillation
V fib or pulseless V tach
2-4 J/kg up to 10 J/kg or maximum adult dose
Cardioversion
Synchronized rhythms - A fib, A flutter, or SVT
0.5-1 J/kg
Repeat dose 2 J/kg
Next step when unable to obtain peripheral venous access w/in 90sec?
Another route
Drugs via ETT
Intraosseous (IO)
Femoral vein
Appropriate Flush Volume
0.25mL/kg NS
Infants 5mL
Children 10mL
Care After ROSC
Titrate FiO2 (aim Pox 94-99%)
Assess rebound arrest - hyperkalemia treatment (dialysis) or needle decompression for tension pneumo (chest tube)
Confirm ETT & line placement
Avoid hypothermia, hyperglycemia, & seizures
Cooling after arrest?
Update the family
ICU transfer
