Resuscitation Flashcards
Incidence of childhood cardiopulmonary arrest:
60 per 1 million children per year have cardiopulmonary arrest
Highest incidence in under 4 year age group
In admitted children:
1 percent of pediatric admissions have cardiopulmonary arrest
5 percent of admissions to PICU
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Age distribution of cardiopulmonary arrest:
Skewed toward infancy Over half (56%) under 1 year of age
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Outcomes of pediatric cardiopulmonary arrest:
Out of hospital: 12% survival to discharge 4% neurologically intact In hospital: 28% survival to discharge 19% neurologically favourable outcomes
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Prognosticators in pediatric arrest:
What: presenting rhythm. VF more likely to survive compared to asystole, severe bradycardia, or PEA
When: prolonged resuscitation greater than 20 minutes frequently considered the greatest indicator of fatality. Survival decreases 2% every 1 minute
Where: out of hospital or in hospital. Initiation of CPR by bystanders or paramedics after witnessed arrest associated with 4 fold better survival than when CPR initiated by physicians on hospital arrival
Why: arrests post trauma or submersion associated with better survival than with primary cardiac causes. Blunt trauma worse survival than penetrating trauma
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Why does intraosseous infusion work?
Bone marrow is composed of a series of interconnected sinusoids that are fed and drained by veins that traverse the cortex and connect with central veins.
In animal models, medications infused into the intraosseous space reach the heart rapidly (less than 60 seconds).
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PALS recommendations for epinephrine in pulseless arrest (PEA or asystole):
Asystole or pulseless arrest (PALS [Kleinman 2010]): Infants, Children, and Adolescents:
IV, I.O.: 0.01 mg/kg (0.1 mL/kg of 0.1 mg/mL solution) (maximum single dose: 1 mg); every 3 to 5 minutes until return of spontaneous circulation
Endotracheal: 0.1 mg/kg (0.1 mL/kg of 1 mg/mL solution) (maximum single dose: 2.5 mg) every 3 to 5 minutes until return of spontaneous circulation or IV/I.O. access established. Note: Recent clinical studies suggest that lower epinephrine concentrations delivered by endotracheal administration may produce transient beta 2-adrenergic effects which may be detrimental (eg, hypotension, lower coronary artery perfusion pressure). IV or I.O. are the preferred methods of administration.
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PALS recommendations for epinephrine in bradycardia:
Bradycardia (PALS [Kleinman 2010]): Infants, Children, and Adolescents:
IV, I.O.: 0.01 mg/kg (0.1 mL/kg of 0.1 mg/mL solution) (maximum dose: 1 mg or 10 mL); may repeat every 3 to 5 minutes as needed
Endotracheal: 0.1 mg/kg (0.1 mL/kg of 1 mg/mL solution) (maximum single dose: 2.5 mg); doses as high as 0.2 mg/kg may be effective; may repeat every 3 to 5 minutes as needed until IV/I.O. access established. Note: Recent clinical studies suggest that lower epinephrine concentrations delivered by endotracheal administration may produce transient beta 2-adrenergic effects which may be detrimental (eg, hypotension, lower coronary artery perfusion pressure). IV or I.O. are the preferred methods of administration.
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Resuscitation drugs that are effective when given through the ETT:
NAVEL: Naloxone, Atropine, Versed, Epinephrine, Lidocaine
With the exception of epinephrine, all drug doses are the same when given via the ETT.
Epinephrine should be given at higher doses (0.1 mg/kg) when given via the ETT.
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Are there minimum dosage requirements for atropine?
Yes - at doses less than 0.1 mg IV atropine can make bradycardia worse. Therefore for children < 5 kg give a minimum dose of 0.1 mg (usual dose 0.02 mg/kg
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What are the effects of dopamine at various dosing ranges?
At 1-5 mcg/kg/min dopamine increases renal blood flow and urine output (dopaminergic effect)
At 10 to 20 mcg/kg/min dopamine causes peripheral vasoconstriction and increases blood pressure (alpha adrenergic effect)
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Adenosine half life, MOA, and dosing
Half life approximately 10 seconds
Slows conduction through AV node
Initial dose of 0.1 mg/kg given by rapid push followed by rapid saline flush
Second dose of 0.2 mg/kg if first dose given correctly but ineffective
Usual adult dose 6 mg IV then 12 mg IV
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Role of bicarbonate in paediatric resuscitation:
Not recommended for routine use in pediatric resuscitation
Only effective in reversing metabolic acidosis if effective ventilation
Combines with proton to form complex molecule that splits into CO2 and H2O
In absence of effective ventilation, byproduct cannot be removed and buffering capacity of bicarbonate is removed
After effective ventilation, compressions, and epinephrine have been given, consider sodium bicarbonate in prolonged resuscitation
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Most common presenting rhythm is paediatric cardiac arrest:
Asystole
VF much more common than previously thought
Survival: VF > asystole > PEA
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How does IV epi help in VF arrest?
Coursens VF and makes it more likely to convert
High amplitude/coarse VF more readily converted than low amplitude/fine VF
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What treatment is recommended for VF or pulseless VT when electric shock is ineffective?
Amiodorone can be used for shock refractory or recurrent VF or pulseless VT
If amiodorone not available, can consider use of lidocaine (no pediatric evidence)
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