Pediatric Cardiopulmonary Resuscitation



Pediatric Cardiopulmonary Resuscitation


Suzan Schneeweiss



Introduction



  • Pediatric cardiac arrest is usually caused by an underlying respiratory abnormality


  • In general, the myocardium in children is normal, and the final common pathway leading to cardiac arrest is usually hypoxia


  • Second most common cause of cardiac arrest is circulatory failure from hypovolemia (loss of fluid or blood) or sepsis


Airway


Open the Airway



  • Similar maneuvers may be used in children and adults


  • Characteristics of childhood airway:



    • Large tongue proportional to the oral cavity


    • Higher and more anterior larynx (C3-4) vs (C5-6)


    • Long, floppy epiglottis


    • Subglottic area is narrowest portion of the infant larynx


    • Large head: when lying supine on backboard, neck is relatively flexed due to the large occiput and may obstruct the airway; if there is no evidence of trauma a towel placed under the head and shoulders will help position the airway


Tracheal Intubation



  • Best method for establishing and maintaining a patent airway in children who are comatose or in those with respiratory or cardiac arrest



  • Rapid sequence intubation to facilitate intubation and reduce complications



    • Sedative, neuromuscular blocking agent and other medications to sedate and paralyze patient


    • Requires skilled personnel


  • Verification of tube placement: clinical assessment and confirmatory devices



    • End-tidal CO2 monitor; positive waveform or color change


    • Consider esophageal dectector device in children > 20 kg with a perfusing rhythm


    • Bilateral chest movement; equal breath sounds over both lung fields


    • Listen for gastric insufflation sound over stomach


    • Check oxygen saturation


    • If uncertain, perform direct laryngoscopy


    • Chest X-ray: confirm placement (not in right mainstem bronchus or high position)


  • If deterioration of patient condition, consider DOPE:



    • Displacement of tube from trachea


    • Obstruction of endotracheal tube


    • Pneumothorax


    • Equipment failure


Estimation of Size of ETT in Children



  • Child > 1 yr = (age/4) + 4 (uncuffed tube)


  • Internal diameter of ETT = size of child’s little finger (less reliable)


  • Length-based resuscitation tapes (Broselow® tape)


  • Consider cuffed endotracheal tube in hospital setting


Laryngeal Mask Airway (LMA)



  • If endotracheal tube placement is not possible, LMA acceptable adjunct for experienced providers


  • Contraindicated if intact gag reflex


  • Does not protect airway from aspiration



  • More difficult to maintain during patient movement than ETT


  • Should not replace BVM ventilation


  • LMA sizes:



























    •

    Neonates

    1-1.5


    •

    7.5-10 kg

    1.5


    •

    10-20 kg

    2


    •

    20-30 kg

    2.5


    •

    30-50 kg

    3


    •

    > 50 kg

    3-4



Breathing


Impending Respiratory Failure



  • Increased respiratory rate and effort or decreased breath sounds


  • Increased work of breathing



    • Nasal flaring, use of accessory muscles


    • Head bobbing, grunting


    • Stridor and/or prolonged expiration


  • Decreased level of consciousness or response to pain or stimulation


  • Poor skeletal muscle control


  • Slow or irregular respirations (ominous sign of impending arrest)


  • Cyanosis


  • Note: Tachypnea without other signs of respiratory distress quiet tachypnea is often an attempt at maintaining normal pH (compensatory respiratory alkalosis) in response to metabolic acidosis


Bag-Valve-Mask (BVM) Ventilation



  • As effective as ventilation through endotracheal tube for short periods


  • Caution against overventilation




    • Reduced cardiac output, cerebral blood flow, and coronary perfusion


    • Air-trapping and barotrauma: increased risk of stomach inflation, regurgitation, and aspiration


  • Two-person technique more effective than one-person technique



    • One person maintains open airway with jaw thrust and tight mask-to-face seal while other person compresses ventilation bag


Self-Inflating BVM Device

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Jun 22, 2016 | Posted by in EMERGENCY MEDICINE | Comments Off on Pediatric Cardiopulmonary Resuscitation

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