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Major Changes

CAB instead of ABC

Adequate depth of compressions
AED infant use
Defibrillation energy dose
Revised of capnography to determine Enotracheal placement
Meds using during cardiac arrest and shock

1. Immediate CPR with no pulse palpated after 10 seconds

a. Begin with the chest compressions, NOT rescue breaths
i. 30 compressions
ii. Compressions more important than ventilations
1. Most important
a. High quality chest compressions
b. Defibrillations
b. Most pediatric axphyxiation usually
i. Increased the likelihood that bystander CPR will be provided
c. Empasize high quality CPR
i. 2 inches
1. ROSC- return of spontaneous circlation
i. Provide chest compressions for anyone with
no pulse or gasping for air
ii. Start CPR within 10 seconds
iii. Compress at AT LEAST 100 per minute
1. 1/3 depth of chest
2. 2 thumb encircling hand technique
iv. Allow complete chest recoil
v. Minimize interruptions to less than 10
seconds
vi. Give effective
1. 30:2 for 1 person
2. 15:2 up to puberty for 2 person
3. 30:2 after puberty for 2 person
b. Only needs to be 25-30% of normal, do not want to
create positive pressure in the chest because it will
limit the flow of the blood
c. 2 joules for
d. Refractory VF- 4 joules or higher, not to exceed 10

2. End tidal CO2- value is consistently less, suggesting that

efforts should improve the quality of CPR
a. Waveform capnography would reduce the need for
stopping chest compressions for a pulse check
i. Hyperoxia
ii. Arterial oxygen tension between 80 and 500
mg of mercury
iii. Titrate oxygen to 94-99%
1. Calcium and etomidate
a. Calcium provides no benefit and
may be harmful
i. Do not use unless for CCB
overdose, hyperkalemia
b. Edominate
i. May be harmful
b. Channelopathies- genetic mutations
i. Helps for relatives to know
ii. Obtain
1. Syncopal episodes, seizxures,
unexp,ained accidents or drownings,
all prevois
2. If discovere, survivint relatives should
get checked
Questions

Channelopathy- an unexplained cardiac arrest event due to an ion balance (K,

Na, Mg, Ca)
o Something is wrong with their channels for a kid to go into sudden
cardiac arrest without any history
Not a channelopathy if big right atria, etc.
Children in ER, if age under 13 and the lab values are off the tiniest bit, it
alerts that it is a critical lab value
o Kids have to be perfect; their computer programming is off a little,
things can shut
Potassium is number one
Sodium number two
Tall tented T waves, 240/110, K 13.2!
o Syncope, runs of V-tach = irritable heart
o Then goes into V-fib
2 J per Kg
Full 2 minutes of CPR
Cannot give epi until 2nd shock
Drilled an IO
Sodium bicarb to kid
25 mEq
Push 1/2

Didnt have to shock a second time, no epi

End Stage Renal Failure, abdomen, K level increasing,
extremely fatigued, kidney transplant needed
o Guessing 3 weeks to 1 month

SVT and VTach

SVT or V-tach if unstable, alive babies
Stable- medicine
Unstable- medicine

SVT/V-tach DEAD
2/4
Dont go to 10
Always go to the next highest setting as long as it does not exceed 10 J/kg

SVT/V-tach ALIVE UNSTABLE

Synchronized cardioversion for unstable
1 J/kg, 2nd dose is 2 J/kg

Lifepak- 30, 60, 70, 100

Waveform capnography- when we intubate, the waveform and the number must be
together; just a number and no waveform, not
Tell us that it is IN THE TRACHEA
Now our capnography must be AT LEAST 10 (better chances of survival if 1020 or even in 20s)(we cannot produce anything higher than 35)
Anytime we have abrupt RAPID increase in CO2-O2 exchange, heart
beating again and pulse back!
No spike = PEA
If CO2 still at 16
If CO2 at 54

5 Drug Doses

Unconscious and no gag

Use OPA
Nose to jaw
Unconscious
Position the victim
Apply the EC clamp technique
Open airway
Squeeze bag slowly
1 breath every 3-5 sec
Uncuffed Endotracheal tube and Cuffed endoctracheal tube: Know these!
Sniffing position
Cuffed tube preferred if poor lung compliance
Inflate with minimum cuff needed
Preoxygenate with normal tidal breaths for 3 minutes
Breath sounds should be audible BUT NOT over stomach
o After 6 breasts, CO2 detector tells you its in the airway, NOT in specific
position in trachea
Tracheal tube position confirmed
DOPE
Displacement (tube), O (obstruction), P (pneumothorax), E
(equipment, check this)
Corner of the mouth to earlobe- OPA with no gag, APNEIC and NOT
BREATHING (often, respiratory tissues)
Management of tube
o 30:2-15:2 goes away
o Now every 8-10 per minute OR 1 every 6-8 seconds
Only requires 40-60 mL of air for 0-6 months
Careful for the fact that if you squeeze a pediatric bag, it
delivers 250
DOPE acronym
o Displacement- if they are intubated, going to put waveform
capnography on a tube
Waveform has a variation of 3 seconds
In cardiac arrest event, number 1 cause of change is CPR
(if in ROSC)
Then DOPE acronym- where was the tube at the teeth? Is
it still 21?
O- obstruction
o See secretions or hear gurgles when

Pneumothorax- unequal chest rise, breath sounds, grab

stethoscope and check for missing lung sounds
E- equipment-

I O Access

Proximal tibia
o Contraindications
o Oseogenesis Imperfect

Meds

Epinephrine (IM, GLASS VIAL) Anaphylixas, Respiratory

o 1:1000
Anaphylaxis or
0.01 mg/kg so 18 kg, 0.18 mg, how many ml? 0.18 mL epi (1:1)
concentration
23 kg, 0.23 mg, 0.23 mL

Epinephrine (IV, preloaded) 1st line

o 1:10,000
0.01 mg/kg so 0.18 mg, so 1.8 ml
13 kg,

Atropine Brady 2nd Double it!

o .02 mg/kg = 0.36 mg, 3.6 mL

Amiodarone- V FIB
o 5 mg/kg = 5 x 18 = 90 = 1.8 ml
o Epi, 3 shocks, same as epi

Adenosine- IV
o 0.1 mg/kg= x 18 = 1.8 mg = 0.6 mL
6 mg/2 cc or 3 to 1 ratio
o 0.2 mg/kg = x 18= 1.2 mL
o Then second dose and double it
o Unstable SVT- 1 J/kg so 12 j, then 24 j

Evalute- Identify- Intervene

Primary Assessment- ABCDE
Assessment- vital signs, O2 sat
Airway
Breathing

Circulation
Disability
Exposure

AWC
Appearance, work of breathing, circulationAppearance- lethargy, grunt to keep alveoli open
WOB
Circulation
Skin turgor, cap refill, sunken in fontanels, eyes

Shock- Tank? Pipe? Pump?

20 mEq
Hypovolemic Shock- tank is low, fill them up, 20cc per kg, N/V, diarrheas (Ins
& Outs) (dehydration)
Distributive- leaky, vasodilatation; tank is full; pressure is lower, plenty of
fluid
Sepsis- 2-6 years old (meningitis)
Anaphylactic- basics then respiratory or shock or both; 1:1000 IM so
need stronger, epi causes vasocontriction, then Benadryl so the
histamines go away; in 8-10 mins; albuterol is respiratory
Neurogenic- pipe is HUGE, give dopamine (levofed, leave them dead),
half life is short, traumatic event, low pressure, low heart rate, oh crap.
Spinal cord injury, dopamine increases your pressure and HR. Levofed,
leave em dead has a longer half life.
Cardiogenic- channelopathy no, congenital heart defects, put them on the
heart monitor but now BP is hypotensive, brady or tachy, goal is to treat the
brady or treat the tachy and then see what happens; dont think about fluids;
heart has too much blood, goes into heart failure, treated v-tach
Obstructive shock- obstructed blood flow, tension pneumothorax, air has
leaked in the thoracic, cardiac tamponade
70 + 2x age in years =
If kid is 7, 84 is lowest

Anything below that makes them hypotensive and giving them fluids and
treating them for shock

Secondary Assessment- SAMPLE

Identify- Respiratory, Circulatory,
Respiratory- upper, lower, lung tissue,
Circulatory

Upper Respiratory

Croup
-barking, seal-like cough; crying; nebulized epi is the solution
Epiglottitis
Major drooling and high grade fever; ant; crychocthyroidectomy
Anaphylaxis
Occlusion

Lower Respiratory
Bronchiolitis
Asthma- kids and adutls; wheezing exercise, pollen; each time child has
asthma attack, equal or greater than last in distress; those patients you are
screwed once behind the curve (atrovent, steroids, epi 1:1000 (prolonged
expiratory), shark fin waveform (albuterol short and atrovent long), severe
respiratory distress- steroids, 1:1000, BVM
Lung tissue disease
Pneumonia- expect O2 sats to be low, 02 is 92%; threshold of 95 move to 90
(decreased oxygen saturation)
Disordered control of breathing- what about hypoglycemic or brain injury?
Everything else that can make you have irregular breathing pattern, postictal;
pneumothorax
Core Case
-fast breathing, lethargic, work of breathing, didnt care RN, nebulizer

171 heart rate, 90 with nebulizer, 92/60, 70+2x2= 74 so okay, PaCO2 50s, lactate
was 0
Increased rep rate, increase resp effort, expiratory wheezes

Intercostal retractions, mottled skin, only on NC, grunting, 171 over 87, 66/40 and
HR 170, O2 sat 88; pneumonia (lung tissue disease), nebulizer (should be 70 at
least)

Sedated child- alarms going off, low tidal volume, 68 percent oxygen so vent is
beeping; DOPE- obstruction, pneumothorax, equipment running
Needle decompress to reinflate the lung
Tension pneumo- obstructive shock

HR <60, unresponsive, and poor perfusion = start CPR

1st line bradycardia, 35 kg, 0.35 mg or 3.5 ml (epi 1:10000), atropine 7 mg= 7 mL,
repeat atropine 2x (so 3 total) , atropine works on vagal induced bradycardia,
atropine; law of PALS said we will never exceed adult doses (go to max allowed for
this kid), only give 0.5 mg of medicine or 5 mL

Study the followingShock, respiratory, bradys, tachy, cardi dosage, fibrillation dosage, drugs and doses