NOTE
All the medical
procedures and drug administration mentioned in this text
should be done only under a senior doctor’s consultancy.
PAEDIATRIC BLS (BASIC
LIFE SUPPORT) ALGORITHM
Safety first!
Stimulate. Don’t shake the kid, but with
your one hand on its forehead and the other at its arm and
shake its arm.
Assess for unresponsiveness.
Call loud its name and say ‘wake up’ or
‘are you Ok?’
No response: shout for
help!
Open airway (head tilt & chin lift
or jaw thrust, on trauma only jaw thrust)
Check for any foreign object and remove
it with a single sweep.
Breathing assessment
Look, listen feel for 10sec.
a.
Breathing: place in
recovery position.
b.
Not breathing
Place the baby supine at a neutral position
(place a folded towel under the baby’s shoulders). However,
place a child > 1 years old supine on a ‘sniffing position’
(with increased head extension than in neutral position)
Open the airway (jaw thrust or chin lift,
use jaw thrust on trauma).
Give 5 rescue breaths (with a pocket mask
or if available perform BMV, Bag Mask Ventilation with a
self inflating Bag Mask with reservoir). On mouth to mouth
rescue breaths don’t forget to close the victim’s nose.
On infants < 1 years old cover with
your mouth the mouth and the nose of the baby, if you use
mouth to mouth ventilations.
During each rescue breath check for visible chest
expansion.
Check for pulse (10 sec) (carotid on children,
brachial/ femoral on infants < 1 years old, umbilical
on newborn)
A)
Pulse: Give 1 breath / 5 – 6 sec (10–12 breaths /min). Recheck pulse
every 2min.
B)
No pulse or HR < 60:
Start CPR compressions: rescue breaths ratio 15:2 (30:2
with a single non professional rescuer). On newborn the
CPR ratio is 3:1.
Compressions 100/min in the middle of the chest. Ventilations 10/
min (1 every 5 sec). The
duration of each ventilation is 1 – 1.5 sec. Ensure full
chest recoil with the compressions. The depth of compressions
is 1/3 of the chest’s diameter.
On infants (< 1 years old) perform compressions with your 2
fingers vertically on the child mid-chest. On newborn perform
the 2 thumbs encircling technique. On small children, but
older than infants (and younger than adolescents), perform
compressions with your 1 hand.
Continue CPR for 1 min
Reassess
Check pulse
No pulse: Activate EMT (Emergency Medical Team) – activate blue code & ask for defibrillator.
However if primary cardiac arrest (e.g. child with known cardiac
disease) is suspected activate EMT and ask for a defibrillator
before starting CPR.
Attach an AED (Automated External Defibrillator) on children >
1 years old. On children 1 – 8 years use pediatric attenuator,
but if unavailable, use AED as it is.
ABCDs – PRIMARY SURVEY
·
Primary
survey:
·
On
A (airway) we
check the airway’s patency. Open the airway. Is airway patent
(e.g. the patient talks) or threatened (stridor or ‘snoring’)
or obstructed?
o
A
is also C Spine immobilization (on suspected injury). We
open airway with jaw thrust or chin lift (we use jaw thrust
on suspected C – spine injury), we do suction (e.g. of vomits),
we place an oropharengeal airway (if the airway’s patency
is threatened and also if no gag reflex) or nasopharyngeal
airway (contraindicated in apnoea, nasal injury, cribiform
fracture and basal skull fracture) and we consider soon
a permanent airway (e.g. ET endotracheal intubation).
o
On
A we also check tracheal position and also in older children
for JVD (jugular vein distension).
·
Traps
on A (airway) are cribiform and face trauma and also base
skull fracture with ear or nose leakage of CSF, racoon eyes,
blood from the ear and Battle sign with haematoma behind
the ears (in the above cases the nasal airway or the nasogastric
tube are contraindicated because they may enter to the brain!).
·
On
B (breathing)
we check RR (respiratory rate), chest expansion (if it is
equal bilaterally, otherwise suspect e.g. flail chest on
trauma), we ausculate the chest (is breathe sound bilaterally
equal? Any wheezing?), we percuss the chest (any tympany?)
and take oxygen saturation (SpO2).
o
Also
we check for central cyanosis (tongue & lips, central
cyanosis is always combined with peripheral) or peripheral
cyanosis (finger nails – exclude hypothermia). SpO2 is unreliable
on methemoglobinemia (may be manifested with asymptomatic cyanosis, it may be caused from drugs)
and CO (carbon monoxide) poisoning.
o
What
is the respiratory effort and depth? Is breathing shallow
and laboured? Is oxygen saturation low? Does the child has
sub and intercostals recession, xiphoid retraction, nasal
flaring, use of assessor muscles (e.g. sternoclidomastoids),
head bobbing up and down with each respiration, see – saw
(rocking) respiration (movement of the abdomen during inspiration)
and grunting (babies)? All the above indicate respiratory
distress.
o
Also
always give oxygen:
o
On patients WITHOUT significant
hypoxia (SpO2 Oxygen saturation) and WITH ADEQUATE breathing
we give oxygen with nasal cannula 2 – 4 L/min.
o
On patients WITH significant
hypoxia but ADEQUATE breathing we give O2 (oxygen) with
a non rebreathing face mask with reservoir bag and flow
15 L/min.
o
In case of INADEQUATE breathing
or APNEA we perform BMV bag mask ventilation with a self
inflating bag with reservoir and oxygen supply and flow
15 L/min.
o
We keep always SpO2 oxygen
saturation > 90%.
o
Patients with significantly
increased or decreased RR respiratory rate need BMV bag
mask ventilation.
o
Also
on patients with GCS <_ 8 we intubate (we use RSI rapid
sequence intubation if GCS is >3).
·
Traps
on B (breathing) are vulnerable ages (on children rib fractures
are rare; if they occur they indicate severe lung injury
such as lung contusion).
·
On
C (circulation) we check pulse (radial and carotid on children, brachial
and femoral on babies). Is it fast and thready?
Is it regular or irregular? BP and pulse pressure (SBP systolic
BP – DBP Diastolic BP). BP will fall with > 40%
volume loss.
o
We
obtain vascular (IV/IO) access (2 wide IV lines on trauma).
On hypovolemia (from trauma or dehydration) we give NS (normal
saline) or RL (Ringers - Lactated), reassess and also consider
early to transfuse blood (if not type available give Group
O Rh negative). On trauma fluids should be warm (39 degrees
C)! On hypovolaemic children we give 20 ml/kg fluids bolus
over 5 – 20min. If no response, we repeat 20 ml/kg and if
shock still remains we give 15 ml/kg packed red blood cells
PRC to 10 ml/kg crystalloids or we give 10 ml/kg whole warmed
blood. On hypovolaemic
newborns we give10 ml/kg fluids over 5 – 10 min (in arrest).
o
After
IV access we also take blood for Labs (including pregnancy
test on child bearing age women, toxicology, coagulation
and blood type and crossmatch – we ask blood units for transfusion).
o
Signs of shock:
o
On children, on < 25%
of circulating blood volume loss, there is mildly increased
HR heart rate, moderate increased RR respiratory rate, normal
or increased (!) peripheral pulse volume, normal or increased
capillary refill time, cool/pale skin and mild agitation.
Οn shock, systolic
BP will fall if more than 40% of circulation blood volume
is reduced on children!
o
Ο C we also look the color and temperature of the skin (a cold clammy mottled
or pale or with cyanosis skin may indicate shock, however
exclude low ambient temperature!), the peripheral pulses,
the capillary refill time (normal is when < 2 sec, on
5 sec finger nail pressure or on the babies on sternum pressure),
the LOC (level of consciousness) and also for babies the
interaction with the parents or the presence of uncontrolled
cry.
o
We
also check the preload with JVD (jugular vein distension).
In case of JVD, we need to exclude heart failure, pulmonary
embolism (rare), cardiac tamponade and tension pneumothorax).
We also check for leg and pulmonary oedema (both are rare
on children) and liver distension (that is more significant
sign on children!).
o
We
also connect to a monitor, and – if indicated (e.g. arrhythmia
or heart contusion on trauma) we take a 12 lead ECG. If
there is time, we may also take ABGs (arterial blood
gases) to check e.g. for acidosis.
·
On
D (disability) we check AVPU (Alert, responds to Voice, responds to Pain, Unresponsive),
or if there is time (and always on trauma) we check GCS
(Glasgow comma scale). We also check pupil’s size & reaction to light and also
for abnormal postures of flexion (decorticate) or extension
(decerebrate). On GCS <_ 8 intubate (use paralytics –
anaesthetics if GCS > 3). On AVPU, response only to pain
indicates GCS about 8. Check then the GCS.
·
Traps
on D (disability) are:
lucid interval on epidural hematoma, brain’s vasoconstriction
from hyperventilation and also increasing ICP during intubation
(prevent it with lidocaine and etomidate – the last is contraindicated
on hypotension – in that cases stabilize first the patient
with fluids).
·
Οn E (Expose, Environment)
we expose the patient (from his/her clothes) and check the
skin for clues (wounds, rash, belt sign on car accident
etc). We also perform log roll and check the back. Next
we prevent hypothermia e.g. with blankets. E is also to call
Expert!
·
Traps on E are hypothermia
which complicates clotting.
·
We also check the kid’s
temperature!
·
Aids on ABCDs are ABGs (arterial
blood gases), SpO2 (oxygen saturation), CO2 detector (capnographer
or oesophagal detector) after intubation), Foley, Levine
(nasogastric tube), ECG and FAST/ ultrasound.
DPL (diagnostic peritoneal lavage) is unreliable
on children.
·
Secondary survey οn trauma is the examination from head to toes. We check pulses
and also check for lacerations, edema, deformity, paleness,
tenderness, crepitation, surgical (subcutaneous) emphysema,
joints mobility, sensory examination, reflexes and neurological
examination etc. We use X’ Rays, Doppler, CT etc.
·
The
emergency needs to be transferred to the nearest APROPRIATE
(trauma) medical centre/ hospital.
·
TRIAGE
is based to factors such as ABCs, the available
means (personnel and devices), if we have a mass destruction,
the number of victims, the time and distance for definite
care, the severity of the injury and the bigger chance for
survival (in case of a patient with a very serious injury
that is not compatible with life, or in a case of no pulse,
we go on with the rest patients and ‘flag’ this patient
with black color – or blue in some countries, i.e. expectable
to die). Triage is continuing (dynamic).
·
On
trauma we do not forget log roll.
·
On
secondary survey always we ask AMPLE (Allergy, Medication,
Past medical history, Last meal and Environment/Events).
Some prefer to ask it from the very first.
PULSELESS ARREST, ALS (Advanced life support) ALGORITHM
For initial steps see above ‘BLS’ algorithm.
Attach monitor/ defibrillator.
Attach an AED (Automated External Defibrillator) on children >
1 years old. On children 1 – 8 years use pediatric attenuator,
but if anavailable, use AED as it is.
a.
Shockable rhythm (VF ventricular
fibrillation, pulseless VT ventricular tachycardia).
Gel
(Put gel on chest)
Joules:
1st shock: 4 J/Kg (ACLS: 2 J/Kg for 1st shock).
Paddles (1st paddle below the right clavicle, 2nd
on the left axilla at the left mid-axillary line)
In case of a patient with a pacemaker or
an ICD (implantable cardiac defibrillator), place the defibrillator’s
pads or paddles at least 12 – 15 cm away from the pacemaker
or the ICD to avoid burning the myocardium!
[Before each shock remove oxygen supply
(nasal cannulae or oxygen mask or self inflating bag) 1
meter away or close the ventilator! Ensure no one touches
the patient (say: ‘I am going to shock on three. One, I am clear.
Two, you are clear. Three, everyone is clear’.]
1st Shock
Resume immediately CPR for 5
cycles of 15:2 (2 min)
Reassess rhythm & pulse
Shockable rhythm
2nd shock 4 J/Kg
Immediately resume CPR for 2 min
Give epinephrine (adrenaline) 10 mcg/
kg rapid IV/IO push.
Epinephrine (adrenaline) dose is 10 mcg/kg
IV/ IO namely 0.1 ml/kg of 1: 10.000 solution (1 mg/ 10
ml). If you use ET (endotracheal) rout, although the dose
administration is unpredictable, give 100 mcg/kg (0.1 ml/kg)
of 1: 1000 solution (1mg/ 1ml).
Check monitor/ rhythm
Shockable rhythm
3rd shock 4 J/Kg
Immediately resume CPR for 2 min
Give amiodarone 5 mg/kg IV/IO (diluted
in D5W 5% dextrose) rapid IV push.
Amiodarone may be repeated at max dose
up to 15 mg/kg/day.
4th shock
etc.
ΝΟΤΕS:
·
Give epinephrine every
3 – 5 min (after alternating shocks or every 2nd loop).
·
Rotate compressors every
2 min.
·
For arrest from VT with hypomagnesaemia or on
Torsades de points give MgSO4 magnesium sulphate 25 – 50
mg/kg IV/IO (diluted in D5W 5% dextrose), over 10 – 20 min
(max 2 gr).
·
On ACLS alternative to
amiodarone is lidocaine 1,5 – 2
mg/kg IV/IO (it may also given via ET).
·
After intubation, compressions
and ventilation are performed asynchronized. This is not
the case on newborn ALS.
·
On infants, if infant
paddles are unavailable you may use anterior – posterior
placement of the paddles.
·
When the defibrillator/
AED is analyzing the rhythm and also during the defibrillation
ensure no one touches the patient.
b.
Non shockable rhythm (asystole
or PEA Pulseless Electrical Activity)
In case of asystole
1.
Check another lead.
2.
Check if electrodes are
detached.
3.
Increase Gain and sensitivity
of the monitor.
On asystole or PEA:
·
Resume CPR.
·
Perform ET (endotracheal)
intubation and establish IV/IO access. IO access is the
rout of choice on PEA or asystole!
·
First give epinephrine
10 mcg/ kg (0.1 ml/kg of 1 : 10.000 solution) rapid IV/IO
push. Repeat every 3 – 5 min (every 2nd loop).
·
Also give atropine 20
mcg/kg (0.02mg/kg) (min 100mcg i.e. 0.1 mg) on asystole
with P waves or suspected vagotony (from increased vagal
tone) or PEA with HR < 60. Repeat atropine every 3 –
5min (every 3 min on asystole) to max of 3mg (ACLS: max
dose 1mg on children and 2 mg on adolescents).
·
Consider TCP (Tran –
Cutaneous Pacing) if bradycardia is caused by complete heart
block or Mobitz (II) 2nd degree AV block or sick sinus syndrome
or on a transplanted heart.
·
On PEA, in case of suspected
hypovolaemia, give 20 ml/kg (10 ml/kg over 5 – 10 min for
newborn) bolus normal saline.
·
Check also reversible
causes (6 Hs and 6Ts).
TERMINATION OF ALS
Consider termination of ALS (advanced life support) if acceptable
BLS (basic life support) was provided, advanced airway was
placed and successfully maintained, shockable rhythms were
defibrillated, IV/IO access was established, al the appropriate
drugs were administered, potentially reversible causes were
ruled out or corrected and the family has been updated on
the probable negative outcome of continued ALS.
NOTES ON ARREST:
·
Administration
of medications (such as adrenaline) on peripheral lines
on emergencies should be followed immediately by flush with
normal saline (2 – 5 ml on children) and elevation of the
extremity for 10 – 20 sec to facilitate drug delivery to
the central circulation.
·
In
case we use the ET (endotracheal) rout for drug administration
we give higher doses than the IV dose and flush the drug
with 1 – 2 ml NS (normal saline) and ventilate. The ET rout
gives unpredictable dose of drug. It is not recommended
on newborn. Also glucose is contraindicated via ET rout.
·
Many
of the drugs referred below, as well as fluids, can be administrated
via IO (intra - osseous) rout, especially on children.
·
IO
rout is the rout of choice on children with PEA (pulseless
electrical activity), asystole and also if 3 attempts of
IV access have failed or take more than 90 sec.
·
Endotracheal
doses (e.g. epinephrine, lidocaine, atropine, naloxone,
amiodarone) is 2 – 2.5 times the recommended IV/IO dose.
Glucose (dextrose) is NEVER given endotrachel route.
Also DON’T give glucose with blood.
·
Dextrose dose on hypoglycemia
is 5 – 10 ml/kg of 10% dextrose. On neonates the dose is
2.5 ml/kg. Never give it via ET (endotracheal tube) and
don’t mix it with blood. On newborn dextrose may be useful
on arrest.
·
Naloxone dose is 100
mcg /kg (0.1 mg/kg) IV/IO/IM for kids < 5 years old and
2 mg for children > 5 years old. Avoid it on a newborn
of a chronic opioid abuse mother because it may manifest
withdrawal syndrome (in this case call expert).
·
Bicarbonate dose on arrest
is 1mEq/kg (1 mMole/ kg) of 8.4 % solution IV/IO. On newborn
use 4.2% solution. Don’t mix them in the same line with
epinephrine (adrenaline) or other sympathiticomimetics such
as dopamine. At least clean with saline the line.
REVERSIBLE CAUSES OF ARREST TO RULE OUT OR CORRECT
Reversible causes to be excluded and corrected in arrest are the
6 Hs & 6 Ts.
The 6 Hs include Hypovolemia, Hypoxia, Hydrogen ion (acidosis), Hypo/hyperkalemia,
Hypoglycemia and Hypothermia.
The 6 Ts include Toxins/Tablets
(poisoning), Tamponade cardiac, Tension pneumothorax, Thrombosis
coronary, thrombosis pulmonary and Trauma.
·
Hypovolaemia causes narrow
QRS tachyarrhythmia.
·
Hypoxia causes narrow
QRS bradyarrhythmia.
·
Acidosis usually causes
bradyarrhythmia or other arrhythmias.
·
Hyperkalemia causes very
tall (tended) peaked T waves (T waves larger than R waves
in > 1 lead !), 1st degree AV (atrioventricular)
block, sinus bradycardia, AV blocks, flattened or absent
P waves, ST depression (!), S & T waves merging, wide
QRS, VT, arrest (pulseless VT, VF, asystole, PEA).
·
Hypokalemia causes QT
prolongation (such as hypomagnesaemia), flat T wave, 1st
degree AV block, U waves (!), ST elevation (!), variable
arrhythmias, VT, arrest (pulseless VT, VF, asystole, PEA).
·
Hypoglycemia causes tachycardia
(may not appear if on β’ blockers).
It also may cause ST depression or AV block. It also (as
well as liver failure) may cause hemiplegia and other focal
neurological signs and seizures.
·
Cardiac tamponade causes
narrow QRS tachyarrhythmia or PEA.
·
Tension pneumothorax causes narrow complex tachyarrhythmia
or bradyarrhythmia (because of the hypoxia) or may cause
PEA.
·
Οn hypovolemia
give 20 ml/kg normal saline bolus (on newborn give 10 ml/kg
over 5 – 10 min) and reassess.
·
Except trauma, suspect
hypovolemia from dehydration (e.g. high fever and/or severe/
prolonged diarrhea and/or vomiting).
·
On hypoxia and acidosis
ensure effective oxygenation and ventilation. Then consider
on acidosis sodium bicarbonate.
·
Consider bicarbonate
on metabolic acidosis (confirmed by ABGs arterial
blood gases), TCA (Tricyclic antidepressants) OD (overdose)
and also on prolonged (> 10 min) arrest. However, its
potentially harmful on patients with hypercarbic acidosis.
·
Suspect electrolyte abnormalities
on history (renal failure, recent dialysis, diuretics, severe
diarrhea or vomiting etc).
·
On hypothermia do only
1 defibrillation and withhold drugs until core body temperature
is > 30 degrees C (86 degrees F).
·
On poisoning/ overdose
consider decontamination, gastric lavage, active charcoal,
whole bowel irrigation, dialysis, antidotes.
·
Tension pneumothorax
is characterized by JVD (jugular vein distension – if not
hypovolemic), absent breath sounds and hyper- resonance
on the affected side, decreased compliance on ventilating.
Late sign is contralateral tracheal shift.
·
Massive pulmonary embolism
is characterized by sudden onset of
dyspnea, pleuritic (on inspiration) chest pain, cyanosis,
and JVD. It may cause PEA.
·
Tension pneumothorax,
cardiac tamponade and pulmonary thrombosis are obstructive
causes of PEA.
ITD DEVICE
ITD device is Impendence Threshold Device. It attaches to the self
inflating bag mask or the tracheal tube. It let the patient
to exhale if spontaneous breathing returns. It also does
not permit the equalization of negative intra-thoracic pressure
in case of hyperventilation. When we use it with BMV (bag
mask ventilation), two rescues need to perform ventilation.
When we open the ITD it has lights that open 10 times/min.
During each light we ventilate.
AIRWAY OBSTRUCTION BY A FOREIGN BODY ACLS ALGORITHM
·
On a child that chokes from
a foreign body:
a.
If the child is conscious
and the cough is effective, we encourage it to
cough.
b.
In case of a choking child
> 1 years old that is conscious but cough isn’t effective
(the child can’t talk, or has stridor, or cyanosis) we give with our palm
(thenar) 5 back blows between its scapulae & 5 abdominal
thrusts (Heimlich maneuver). We give chest thrusts (instead
of abdominal) on pregnant or obese patients, instead of
abdominal thrusts.
We reassess. We repeat the maneuvers until
the foreign object is expelled (we inspect the mouth and
remove any visible object with a single sweep) or the child
becomes unconscious.
If the child becomes unconscious, we call
for help (activate the blue code/ EMT) and go to the unconscious
algorithm.
c.
In case of a choking infant
< 1 years old that is conscious but cough is ineffective
(the baby doesn’t make sounds, does not breathe effectively
or doesn’t cry; or is cyanotic) we call for
help.
The infant may be positioned supine –
lying inverted on our arm – and in that position we give
5 chest thrusts and then turn it opposite – prone (with
a ‘sandwich’ maneuver) – and give 5 back blows). We support the infant’s
head during the maneuvers by cupping its face with our hand
(without obstructing its airway). We continue the maneuvers
until the foreign object is expelled (we inspect the mouth
and remove any visible object with a single sweep) or the
child becomes unconscious.
d.
If the child (in any age)
becomes unconscious: we place the child supine, (neutral position
on infants < 1 years old – we place a folded towel under
the child’s shoulders to keep this position, or use a ‘sniffing
position’ for older children – with a little bit increased
extension than the neutral position) open the airway and
give 5 rescue breaths. If no effective ventilations, we
reposition the kid’s head and attempt to ventilate again!
If still no effective ventilation, we
start chest compressions and go on with CPR for 1 min and
reassess. We inspect the mouth and remove any visible object
with a single sweep.
If still absent or not effective ventilations,
we call EMT (Emergency medical team)/ blue code.
The foreign object may be removed under
direct laryngoscopy with a Magill’s forceps, if available.
Other option is needle cricothyrotomy.
In case the patient resumes breathing,
we place in recovery position.
WHAT TO CHECK ON MONITOR/
ECG
1.
Is there electrical activity
and recognizable QRS?
2.
Which is the ventricular
rhythm? It is 300/ large squares between RR waves.
3.
Are the QRS regular?
If not, exclude e.g. ectasystoles.
4.
Which is the QRS width?
If > 0.08 sec (2 small squares) it is wide. Then exclude
ventricular arrhythmia or BBB (bandle branch block).
5.
Is there atrial activity?
Check for P waves on II and V1 leads.
6.
Which is the relationship
between atrial and ventricular activity? Is it 1:1 each
P followed by QRS) as normal, or is it variable or there
is no relationship?
TACHYARRHYTMIA ALGORITHM ON CHILDREN
·
We give supplemental
oxygen.
·
We connect to monitor
(we put it to II lead).
·
We place IV/IO access,
take blood for Labs and keep it open with normal saline.
·
We have suction and intubation
equipment available
·
We take a 12 lead ECG
We open the monitor on II lead.
Tachycardia is defined as HR > 160 bpm for children > 1 years
old and > 180 bpm for children < 1
years old.
Is the patient is unstable? AN UNSTABLE tachycardia
is characterized by one or more of the following: decreased
LOC (level of consciousness), hypotension, chest pain, heart
failure (e.g. liver enlargement), dyspnea etc.
A.
Narrow complex tachycardia
(QRS <_ 0.08 sec or <_ 2 small squares).
Diagnostic possibilities:
1.
Probably Sinus tachycardia
if compatible history, gradual onset, ECG: present &
normal P waves, beat to beat R- R variability, HR varies
with activity, normal PR and also HR < 220 bpm for infants
(< 1 years old) and < 180 bpm for children > 1
years old. History clues for sinus tachycardia are fever,
hypovolaemia (hemorrhage, dehydration), anemia, fear/ stress,
pain and respiratory failure. On sinus tachycardia treat
the cause!
2.
Probably SVT (Supra –
Ventricular Tachycardia). SVT is characterized by abrupt
onset, non specific & non clear etiology, P wave absent
or abnormal, no beat to beat R –R variability, and HR >
220 bpm for infants (< 1 years old) and > 180 bpm
for children > 1 years old.
Treatment of narrow complex tachycardia:
a.
Stable patient:
Initially we perform vagal maneuvers such as unilateral carotid
sinus massage or to blow the plunger of a syringe or place
an ice bag transiently over the face (place it not immediately
on the face, but on a towel).
If unsuccessful we give adenosine 0.1 mg/kg rapid IVP (IV
push) or IO (over
1 – 3 sec) to max dose of 6 mg.
If unsuccessful, we repeat after 1 – 2 min at 0.2 mg/kg to
a max dose of 12 mg.
Each dose should be followed by 3 – 5 ml saline flush and
arm elevation for 10 – 20 sec. The injection should be performed
on a close to heart vein (e.g. antecubital fossa).
If still unsuccessful, we call expert.
Don’t give verapamil
on SVTs because it may cause hypotension.
b.
Unstable patient:
We perform SYNCRONIZED cardioversion (under
sedation if patient isn’t unconscious).
Gel, Joules (push synchronized button),
paddles & oxygen removal.
1st shock is 1 J/Kg. If unsuccessful, we repeat
with 2 J/kg. We give amiodarone 5 mg/kg IV/IO (diluted in
D5W 5% dextrose), over 20 – 60 min.
Max dose of amiodarone is 15 mg/kg/day. We may repeat
with 3rd shock.
B.
Wide complex tachycardia
(QRS > 0.08 sec or >
2 small squares).
Possible VT (ventricular tachycardia).
a.
Stable patient:
We give adenosine 0.1 mg/kg rapid IVP (IV push) or IO (over 1 – 3 sec) to max dose of 6 mg.
If unsuccessful, we repeat after 1 – 2 min at 0.2 mg/kg to
max dose of 12 mg.
Each dose should be followed by 3 – 5 ml saline flush and
arm elevation for 10 – 20 sec. The injection should be performed
on a close to heart vein (e.g. antecubital fossa).
If unsuccessful, we call expert.
We give amiodarone 5 mg/kg IV/IO over
20 – 60 min. Max dose of amiodarone is 15 mg/kg/day.
b.
Unstable patient:
We perform SYNCRONIZED cardioversion (under
sedation if patient isn’t unconscious).
Gel, Joules (push synchronized button),
paddles & oxygen removal.
1st shock is 1 J/Kg. If unsuccessful,
we repeat with 2 J/kg. We give amiodarone 5 mg/kg IV/IO
over 20 – 60 min. Max
dose of amiodarone is 15 mg/kg/day.
We may repeat with 3rd shock
NOTE
Alternative to amiodarone on ACLS tachyarrhytmia algorithm
is procainamide 15 mg/kg IV over 30 – 60 min.
BRADYCARDIA
Bradycardia is defined as HR < 60 bpm for children > 1 years
old and < 80 bpm for infants (< 1 years old).
Is the patient is unstable?
Adverse signs on bradycardia are hypotension, HR < 40 bpm, heart
failure (e.g. liver enlargement), ventricular arrhythmias
compromising BP, shock and respiratory distress.
Risk factors for asystole are recent asystole, type II (Mobitz
II) 2nd degree AV (atrioventricular) block, complete
heart block with broad QRS and ventricular pauses > 3
sec. In the above factors perform TCP (Transcutaneous Pacing)
a.s.a.p (as soon as possible). TCP is also indicated on
denervated (e.g. transplanted) heart where drugs will not
work.
Relative bradycardia is the phenomenon where HR is faster than
the one that would expected for the patient’s condition.
For example a patient 17 years old with HR 65 bpm and BP
80/ 50 has relative bradycardia because HR is too slow,
relative to (regarding to) the BP.
BRADYCARDIA ALGORITHM
·
We give supplemental
oxygen.
·
We connect to monitor
(we put it to II lead).
·
We place IV/IO access,
take blood for Labs and keep it open with normal saline.
·
We have suction and intubation
equipment available
·
We take a 12 lead ECG
We open the monitor on II lead.
Paediatric bradycardia is usually result of hypoxia!
Check if there
are there any adverse signs (see above)?
a.
If no, we support ABCs and call
expert.
b.
If yes, we oxygenate,
ventilate and intubate. We start CPR if HR< 60 in an
infant or child, in spite of good oxygenation and ventilation.
So if HR < 60 and there are signs of impaired or absent
circulation we start CPR and:
·
We give epinephrine 10
mcg/ kg (0.1 ml/kg of 1 : 10.000 solution) rapid IV/IO push.
We repeat every 3 – 5 min (every 2nd loop).
·
Also we give atropine
20 mcg/kg (0.02 mg/kg) (min 100mcg i.e. 0.1mg) on asystole
with P waves or suspected bradycardia from increased vagal
tone (e.g. from prolonged suctioning or ET endotracheal
intubation). We may repeat atropine every 3 – 5min (every
3 min on asystole) to max of 3mg (ACLS: max dose 1mg on
children and 2 mg on adolescents).
·
Consider TCP (Tran –
Cutaneous Pacing) if bradycardia is caused by complete heart
block or Mobitz II 2nd degree AV block or sick sinus syndrome
or on a transplanted heart.
NEWBORN LIFE SUPPORT ALGORITHM
Birth
Breathing or crying?
Good muscle tone?
Term gestation? Preterm (premature) is a newborn of < 37 weeks.
Amniotic fluid clear? If not, is meconium thick?
a.
Yes: Provide routine
care, warmth, dry and clear airway if needed.
b.
Νο
1.
Provide warmth. Use warm
towels. After delivery remove the wet towel and cover the
baby’s head and body with a new warm towel, (don’t cover
the face!).
2.
Position the airway.
3.
Dry, stimulate (by rubbing
the baby’s back or flicking its soles) & reposition
the airway.
4.
Clear the airway if needed.
Suction should be applied max for 5 sec. The suction tube
length on newborn is 12 – 14 Fr and negative pressure max
100 mmHg.
On a newborn, firsts we perform suction
of the mouth and next suction of the nose.
Assess breathing, HR (umbilical artery/ ausculate the chest with
a neonatal stethoscope) and color.
Apnoeic or HR < 100 bpm: Call for help!
Give positive pressure ventilations for
30sec
On newborn arrest for the first few breaths the inflation pressure
is kept 30 cmH2O (20 – 25 cm H2O for preterms) and each
rescue breath is applied 5 times, for 2 – 3sec each.
Reassess pulse
HR < 60 bpm
Ensure effective lung ventilation.
Then add chest compressions. Continue CPR for 30 sec.
Reassess pulse
HR< 60 bpm
1.
Further chest compressions.
CPR rate on newborn is 3: 1.
The compressions on newborn are 120/min
and the ventilations on newborn are 30/min. On newborn arrest,
compressions & rescue breaths are perform synchronized
(and not simultaneously), with 3:1 rhythm.
2.
Obtain IV access (umbilical
vein) or IO.
3.
Consider adrenaline.
Epinephrine (adrenaline) dose is 10 mcg/kg
IV/ IO namely 0.1 ml/kg of 1: 10.000 solution (1 mg/ 10
ml). ET (endotracheal) rout for drug administration is
not recommended on the newborn.
4.
Consider fluid administration.
Fluids dose on newborn are 10 ml/kg IV/IO over 5 – 10min.
5.
Consider sodium bicarbonate
(for acidosis e.g. for prolonged arrest – take ABGs) 1 – 2
mEq/kg of 4.2% solution (1 – 2 mmole/ Kg) IV/IO over 2 min. Don’t give it at the same IV line with catecholamines
(e.g. adrenaline or dopamine). At least flush first the
line with normal saline. Also after the bicarbonate administration
ensure good ventilation. Avoid it on hypercarbic acidosis.
6.
Also consider glucose
if no response to adrenaline and bicarbonates.
However in case of bolus of hypertonic solutions
there is a risk for intra-ventricular hemorrhage on premature
newborn. Don’t give glucose via ET rout and also don’t mix
it with blood. The dextrose dose on newborn is 2.5 ml/kg
NOTES
·
On newborn needs intubation
if insufficient bag mask ventilation, or if prolonged ventilation
is needed, or if there is meconium and the baby is cardio-respiratory
compromised or in case of congenital diaphragmatic hernia.
·
In case of thick meconium, we perform
suction on a newborn with HR< 100, absent or insufficient
breaths and not vigorous – with poor muscular tone. We do
suction of the hypo-pharynx under direct vision. Then we
intubate, we perform suction again – we aspirate the meconium
under the vocal cords and next we do orogastric suctioning.
Next, we remove the suction tube with the ET (endotracheal)
tube (together; the meconium is stuck on the ET tube!) continuing
suction of the oropharynx. If after the extubation HR is
< 100 and > 60 we perform again intubation and suction.
If HR is < 60 we perform the newborn arrest algorithm.
·
During CPR, keep the
newborn on neutral position (with a folded towel below its
shoulders. That’s because the baby’s head is larger than
older children’s in which we prefer the sniffing position
with a more increased head extension than the neutral position
). The airway may be kept open with an oropharengeal tube,
until intubation is performed.
·
To prevent hypothermia
on a very preterm baby, wrap it e.g. with a plastic food
grade wrapper, without drying it first with a towel. Next,
place it under a special radiant warmer.
NEVER FORGET:
·
Safety first.
·
Push ‘sync’ synchronized
button on cardioversion.
·
Remove oxygen 1 meter away
or close the ventilator before the defibrillation or cardioversion.
·
Take finger stick glucose
on seizures.
·
Don’t forget IV/IO access
on C – circulation (take blood for labs, keep it open with
normal saline).
·
Rule out and treat 6Hs
& 6Ts reversible causes of arrest (especially in asystole
or PEA).
·
On an unconscious patient
follow the intra hospital CPR/ AED algorithm. Before checking
for breathing, open the airway (chin lift or jaw thrust,
jaw thrust only on trauma).
·
Do not interrupt the
chest compressions (a very common mistake) for any reason.
However, if needed (e.g. for intubation) interrupt it just
for a few seconds. There are special devices that perform
automatically chest compressions.
APPENDIX
(I): COMMON CAUSES OF SHOCK
What to rule out on a shock:
a) Traumatic blood loss. Check for bleeding
in chest. Perform CXR, FAST. Check for pelvic or long bone
fracture. If so, do immobilization.
b) Non traumatic volume loss. Exclude dehydration (diarrhea or vomiting). Also exclude GI
bleeding (e.g. Meckel’s diverticulum). Perform USS (ultrasound).
Call expert.
c) Dysrhythmia or cardiac failure (liver distension
on children) Perform an ECG and CXR (chest
X’ Ray). Call expert.
d) Tension pneumothorax on trauma or after
positive pressure ventilation or spontaneous (bulla rupture).
Are there any decreased
unilateral breath sounds, tracheal deviation (away from
the pneumothorax), hyper-resonant hemithorax on percussion
or distended neck veins (if not hypotensive with blood loss)?
Don’t wait for CXR! Perform needle decompression and next
insert a chest tube.
e) Cardiac Tamponade (on trauma or pericarditis).Are there distended JVD (jugular veins distension), muffled
heart sounds, low ECG voltage and electrical alterance,
or pulsus paradoxus? Perform FAST/ USS (ultrasound).
f) Anaphylaxis. Any history? Is
there angioedema, laryngeal edema with stridor, wheezing,
hives on skin?
g) Spinal Cord Injury – Neurogenic shock with decreased HR.
Check for a motor/ sensory level of paralysis and anesthesia.
Take cervical spine protections. Check rectal tone and check
for blood.
h) Warm skin? If so, consider sepsis, neurogenic
shock, anaphylactic shock, medication poisoning (e.g.β’ or Ca
blockers).
i) Poisons/ medication overdose or SEs (Side
Effects). Also illicit drug abuse, glue sniffing, mushrooms
poisoning.
j) Sepsis and Adrenal Insufficiency.
• PH of venous blood is usually 0,01
– 0,03 lower than the arterial blood PH. Also PCO2 is 6
mmHg higher and bicarbonate is 2 meq/L higher by using venous
blood.
• Anion gap is ([Na] + [K])
– ([Cl] + [HCO3]) and normal values are 12 – 16 mEq/L (usually
10 -1 2mEq/L). Increased anion gap occurs on
DM (diabetes melitus), alcoholics, starvation, lactic acidosis,
renal failure, exogenous toxins metabolized to lactate (cyanide
– CN, CO, ibuprofen, strychnine, toluene, iron – Fe and
INH - isoniazide), or exogenous toxins metabolized to acids
(aspirin, methanol, ethanol, ethylene glucol, paraaldeyde
and rarely with isopropanol), severe hypotension, seizures
and hypoxemia.
• Increased osmolar gap may occur in DKA,
ethylene glycole or methanol or ethanol or isopropanol poisoning.
Osmolar gap ΔOsm = measured Osm
– Calculated O.
APPENDIX (II): GCS (GLASGOW COMMA SCALE)
Eye
Opening (E4)
4 0 – 1 years old: spontaneously; > 1 years
old: spontaneously
3 0 – 1 years old: to shout; > 1 years old:
to verbal command
(not
necessarily to ‘open your eyes’)
2 all ages: to pain
1 all ages: no response
Response to pain is checked
by pressing the patient’s nail’s bed with a pen. If not
response, try supraorbital pressure and sternal pressure.
Best
Verbal Response (V5)
5 0 – 2 years old: appropriate cry, smiles;
2 – 5 years old: appropriate words and phrases; >
5 years old: oriented,
converses
4 0 – 2 years old: cries; 2 – 5years old: inappropriate words; > 5 years old: confused
3 0 – 2 years old: inappropriate cry; 2 – 5 years
old: cries, screams; > 5 years old: inappropriate words
2 0 – 2 years old: grunts; 2 – 5 years old: grunts,
sounds; > 5 years old: incomprehensible e.g. moans
1 all ages: no response
Best
Motor Response (M6)
6 0 – 1 years old: moves spontaneously and adequately;
> 1 years old: obeys
command
5 all ages: localizes pain
4 all ages: flexion withdrawal
3 all ages: decorticate (stereotypical flexion)
2 all ages: decerebrate (stereotypical extension)
1 all ages: no response
Motor response may be e.g.
‘raise your hand’. It is the better response of any limb.
Decorticate posture is characterized by flexion of upper
extremities. Decerebrate posture is characterized by internal
rotation of shoulder & arm pronation and limb extension.
Score: min 3,
max 15. If GCS<_8 the patient needs intubation (RSI rapid
sequence intubation if GCS > 3). GCS <_8 severe injury,
GCS 9 –12 moderate injury, GCS 13–15 minor injury.
APPENDIX (III): Normal vitals:
a) RR (respiratory rate)
Neonates
(until 6th week) min 30/min and max 50/min.
Infants
until preschool age min 20/min and max 30/min.
Teenagers
min 12/min and max 20/min.
b) HR (heart rate)
Neonates min 100bpm and max 150 bpm.
Infants min 80 bpm and max 120 bpm.
Preschool age until school age min 60 bpm and
max 110
bpm.
Teenagers/adults min 60 bpm and max 100 bpm.
c) Systolic BP:
Neonates
until preschool age min is 70 mmHg.
School
age and adolescents min is 80 – 90 mmHg.
Adults 90mmHg
For
children 1 – 10 years old the lower limit of the systolic
BP is 70+ 2 x age (in years).
d) Urine Output
Infants
2 ml/kg/hour.
Children
1ml/kg/h.
Adults
0.5 ml/kg/h.
e) Weight
on children
For
children 1 – 10 years old:
W
(Kg)= (age (years) + 4 ) x 2.
Appendix (IV): Paediatric orotracheal intubation
The tube size is
for pre-term neonates 2.5
– 3 mm ID (internal diameter) or gestational weeks/10.
For term neonates it is 3
– 3.5 mmID.
For infants < 1 year old
it is 4 – 4.5 mmID.
For children > 1 year
old use the formula: (age
(years)/4 ) +4 e.g. for 8 years old kid use a size 8/4 + 4 = 6mmID.
Use uncuffed tubes on children
< 8 years old (up to 5.5 mmID). To estimate the length
of the tube, use the formulas: oral tube length (cm) = (age (years)/2) +
12. Nasal tube length (cm) = age (years)/2 + 15.
On RSI use atropine (to prevent
bradycardia).
About the laryngoscope,
use a straight blade (No 0 or 1) for infants (< 1year old) and neonates.
On children and adolescents use curved blades (No 0, 1,
2 for infants and children; No 3 or 4 for adolescent&
adults).
Don’t forget Sellick maneuver
(cricoid pressure). Nasotracheal intubation is not applicable
for children < 3 years old.
Neonatal orotracheal intubation. The insertion depth at the upper lip (cm) = Weight (Kg)
+ 6 cm.
Use a straight blade (size0 for premature
and size 1 for term newborn).
About the tracheal tube
size use the below guidance. GA is gestational age.
Tracheal tube size 2.5 mmID, Weight <1000gr,
GA <28 weeks, Insertion
depth 6.5 – 7cm
Size 3 mmID, Weight 1000
– 2000 gr, GA28 –
34 weeks, Insertion depth 7 – 8 cm
Size 3 – 3.5 mmID, Weight
2000 – 3000 gr, GA 34 – 38 weeks, Insertion depth
8 – 9 cm
Size 3.5 – 4 mmID, Weight
>3000 gr, GA >38 weeks, Insertion depth
>9 cm
Tracheal tube size (mmID)=
gestational age (weeks)/10.
Insert the tube about 1.5
– 2 cm into the larynx, so that the black mark on the tip
of the tube is just visible thru the cords.
·
DOPES (Displacement of the tube – accidental
extubation or tube in the right main bronchus,
Obstruction of the tube, Pneumothorax, Equipment failure,
Stomach distension) should be checked if respiratory
distress occurs on an intubated
patient.
The first thing
is to extubate the patient and ventilate
him/her for a while with BMV (Bag Mask Ventilation) until
you figure out the reason of the respiratory compromise.
About the Equipment failure check Oxygen, bag mask, ventilator
etc. Stomach distension happens frequently on children,
pregnant and patients (e.g. neonates) with diaphragmatic
hernia.
APPENDIX:
SIGNS OF HYPOVOLAEMIC SHOCK
Signs of hypovolaemic shock (haemorrhage - external or internal
blood loss; or severe dehydration e.g. on severe diarrhea
or vomiting) include: tachycardia (if not on β' blockers
or pacemaker!), fast thready pulse, narrowed pulse pressure
(Systolic BP - diastolic BP), weak peripheral pulses, tachypnea,
decreased level of concioussness (LOC), decreased urine
output (adults < 0.5 ml/kg/h, children 1ml/kg/h, infants
2 ml/kg/h), decreased capillary refill time (>2 sec),
hypotension (late, with > 30% volume loss on adults and
> 40% on children), cool pale skin, diaphoresis (not
on dehydration); also decreased skin turgor (unreliable
on the elderly) and dry mucus membranes (e.g. dry tongue)
on dehydration.
NOTE
Some
information in this text is empirical and its reliability
can't be ascertained. It is suggested to search official
medical articles, books and guidelines in order to ascertain
the medical information of this text.
All
the medical procedures and drug administration mentioned
in this text should be done only under a senior doctor's
consultancy.
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