RESUSITASI JANTUNG PARU OTAK

PADA NEWBORN, INFANT

DAN PEDIATRIC

Bagian Anestesiologi dan Reanimasi

FK Unsyiah RSUZA
Banda Aceh

CHILD VS ADULT
Anak-anak dan dewasa terdapat perbedaan
Anatomy
Physiology
Psychology
penatalaksanaan

Assessment
Equipment
Skills
Pharmacology

Ingat : Anak bukan miniatur dewasa

PRIMARY ASSESSMENT
COMPLETED IN LESS THAN ONE MINUTE
1. AIRWAY
2. BREATHING
3. CIRCULATION
4. DISABILITY ( NERVOUS SYSTEM )
5. EXPOSURE
HHM-ERC.2000

The rapid clinical assessment of in infant or child

Airway and Breathing
Work of breathing
Respiratory rate/rhythm
Stridor/wheeze
Auscultation
Skin colour
Circulation
Heart rate
Pulse Volume
Capillary refill time
Skin temperature
Disability
Mental status/conscious
Posture
Pupils
The whole assessment should take less than a minute

Paediatric Airway

Large head with prominent occiput

Relatively large tongue
Floppy epiglottis
Anterior larynx
Conical narrow airway
Poor chest mechanics
Increased O2 consumption

Child airway

Babies are nose breather

Trachea is 4cm long in neonates
Cricoid is the narrowest part
Use only uncuffed tracheal tubes
Tube ID* (mm) = age years/4 + 4

* ID = internal diameter

Anatomy
Comparation
Adult

Children

AIRWAY + BREATHING
Early control of airway essential
Intubation by most experienced
Cervical spine immobilisation
cervical spine assessment difficult
Decompress stomach
air swallowing common in children
improve ventilation

Child Breathing

Aerophagia often occurs in respiratory

distress gastric distension
Distended gaster restricts lung expansion
Insert nasogastric tube, aspirate gently,
avoid pressing the epigastrium

Circulation

palpation of pulse
heart rate
auscultation of heart sound
capillary refill
peripheral temperature
blood pressure

Heart Rate and Respiration Rate

Age

Awake Heart rate

Sleeping Heart rate

Output

Respiration rate

Infant

120 160 / min

80 180 / min

30 60 / min

Todler

90 140 / min

70 120 / min

24 40 / min

Preschool age

80 110 / min

60 90 / min

22 34 / min

School age

75 100 / min

60 90 / min

18 30 / min

Adolescent

60 90 / min

50 90 / min

12 16 / min

Normal blood pressure

Age

Systolic Pressure

Diastolic pressure

Neonatus ( 1 month)

85 100

51 65

Infant (6 month)

87 105

53 66

Todler (2 Years)

95 105

53 66

School age (7 Years)

97 112

57 71

Adolescent

112 128

66 80

PATHWAYS LEADING TO CARDIO. RESPIRATORY

ARREST :
FLUID
LOSS

LOSS
MALDISTRIBUTION

RESPIRATORY
DISTRESS

RESPIRATORY
DEPRESSION

BLOOD LOSS

SEPTIC SHOCK

FOREIGN BODY

CONVULSIONS

GASTROENTERITIS

CARDIAC DISEASE

CROUP

RAISED ICP

BURN

ANAPHYLAXIS

ASTHMA

POISONING

CIRCULATORY
FAILURE

CARDIAC ARREST

RESPIRATORY
FAILURE

RESUSCITATION for SHOCK

Weight in kg = 2 (age in years + 4)
Estimated blood volume = 80 ml/kg body weight
Crystalloid
20 ml/kg
Assess
response

Colloid
20 ml/kg
Assess
response

Fluid volume and type

An initial fluid bolus of 20 ml/kg is given as fast
as possible
This should be repeated after assessment if there
is no improvement in vital signs

Blood
Urgent
Surgical opinion

The most common mistake in the treatment of

hypovolaemic shocked children is failure to give
enough fluid

Hourly and Daily Maintenance Fluid Requirements

of Children
Maintenance fluid requirements
Weight (kg)

Day

<10
10-20
>20

100mL/kg
1000mL + 50 mL/kg
1500 ml + 20 mL/kg

Hour
4mL/kg
40mL + 2 mL/kg
60 mL + 1 mL/kg

For example :
a 25 kg child would required
1000 ml + 500 ml + 100 ml = 1600 ml

Hydration:
Assessment of the degree of dehydration
Clinical findings

Mild

Moderate

Severe

% body weight loss

Estimation fluid defisit

4-5%
40-50ml/kg

6-9%
60-90 ml/kg

>10%
100-110 ml/kg

Pulse
Blood pressure
Respiration
Skin turgor
Mucous membranes
Peripheral perfusion
Urine

Normal
Normal
Normal
Normal
Moist
Normal
Reduced

, Weak
Normal of low
Deep

Dry
Poor
Oliguria

, feeble
Reduced
Deep & rapid

Very dry
Poor, cool, extremitas
Marked oliguria

Source: Nelson W

Management of dehidration
a. Estimated fluid deficit
b. Rehydration
For example : a 10 kg child is assessed to severe
dehydration with an estimated 10%
Dehydration 10%, 10 kg
EFD : 100 ml x 10 = 1000 ml
Initial fluid resusitation : 20ml/kg (20-30)
Reassess the clinical state
Improved
First 8h

: 50% rest fluid deficit +

fluid maintenance
Second 16h : 50% rest fluid deficit +
fluid maintenance

Respiration
Circulation
Mental status

Non improvement
Repeat : 20 ml/kg/20-30
Resassess
Choice of the fluid :
Rehydration : Isotonic crystalloid
Maintenance : Hypotonic crystalloid

BLOOD REPLACEMENT
Estimated blood volume (EBV) in pediatric patiens
Age

EBV (mL/kg)

Premature infant
Newborn
Infant < 1 y
Child > 1 y

90-100
80-90
75-80
70-75

Normal & acceptable hematocrit (Hct) values in pediatric patients

Normal hct (%)
Age
Premature
Newborn
3 mo
1y
6y

Mean

Range

Acceptable hct (%)

45
54
36
38
38

40-45
45-65
30-42
34-42
35-43

35
30-35
25
20-25
20-25

Mean & lower normal hemoglobin levels

in pediatric patients
Normal hemoglobin (g/100mL)
Age

Mean

Lower limit

1 day
1 week
1 mo
3 mo
0.5 5 y
59y
12 14 y
girls
boys

18
17
14
12.5
13
13.5

13.5
13
13
9
11.5
12

13.5
14

12
12.5

Dallman & Siimes, Oski & Neiman, and Saarinen & Siimes

BLOOD REPLACEMENT TO USE HAEMOTOCRIT LEVEL

Hct 1 Hct 2
X EBV

1. Blood required =
Hct 3

2. Blood required (PRC) = (Hct 1 Hct 2) x body weight (kg) x 1.5

(WB) = (Hct 1 Hct 2) x body weight (kg) x 2.5
Hct1 : Haematocrit before transfusion, the measured
haematocrit
Hct2 : Haematocrit required after transfusion, the desired
haematocrit
Hct3 : Haematocrit of the blood to be given (60% if packed cells)
EBV : Estimated blood volume

Maintenance electrolyte requirement in children

Electrolytes
Sodium : 3-4 mEq/kg/day
Potassium : 2-3 mEq/kg/day
Chloride : 2-3 mEq/kg/day
Calcium : 150-500 mg/kg/day
Phosphorus : 0.5-2 mmol/kg/day
Magnesium : 0.25-0.5 mEq/kg/day
Source : J Allan Paschall

Hypo Natremia
1. Estimated fluid deficit
2. Resucitation from shock : NS / RL
3. Calculated deficit hourly IV rate
Maintenance + deficit Na- / 24 hours
mEq Na+ = (Desired Na+ - Observed Na+) x weight (kg) x 0.6
4. Infuse D5 0.45 NS or D5 NS or D5 LR
5. Add 10 20 mq kcl/l based on renal function and K+ level

Hypokalemia
K : 0.5 1 meq/kg (max.20 meq) / 2 hour
Repeat : 4- 8 hours as need
Monitoring : ECG

Hyperkalemia
CaCl
: 0.1 0.3ml/kg a. 10% solution
CaGluconas
: 0.3-1ml/kg a.10% solution
Nabic : 1-2 mEq/kg + mild to moderate hyperventilation
Glucosa + insulin : 0,5g /kg Glucose + 0.1U/kg insulin / 30-60

THE MANAGEMENT OF CARDIAC ARREST

THREE CARDIAC ARREST RHYTMS :
1. ASYSTOLE
2. VENTICULAR FIBRILLATION
3. EMD ( P.E.A. )

HHM-ERC.2000

20

VENTRICULAR FIBRILLATION:
UNCOMMON IN CHILDREN
RECOVERING FROM HYPOTHERMIA
POISONED BY TRICYCLIC ANTI-DEPRESSANT
CARDIAC DISEASE
ELECTROLYTE IMBALANCE

HHM-ERC.2000

21

PRECORDIAL THUMP

PROTOCOL FOR
VENTRICULAR FIBRILLATION

DC shock 2 J/kg
DC shock 2 J/kg

Within
90 seconds

DC shock 4 J/kg
Ventilate with
High flow O2

I
Consider
Hypothermia, drugs, and
Electrolyte imbalance

1 min or
20 X 5:1
CPR
cycles

II

Adrenaline
100 g/kg IV or IO

HHM-ERC.2000

Intubate
IV or IO access

Adrenaline
10 g/kg IV or IO
If not already
Intubate
IV or IO access

DC shock 4 J/kg
DC shock 4 J/kg

Within
90 seconds

DC shock 4 J/kg
Consider alkalising agents and
Antiarrhythmics after 3 cycles

22

 BEFORE THE ADMINISTRATION OF ANY DRUG :

THE PAT. MUST BE RECEIVING CONTINUOUS
AND EFFECTIVE BLS !
Ventilate with
High concentration O2

DRUGS IN ASYSTOLE

Intubate
IV or IO access

Adrenaline
10 g/kg IV or IO

3 min or
60 X 5:1 CPR cycles

II

Consider IV fluids and

Alkalising agents

Adrenaline
100 g/kg IV or IO

3 min or
60 X 5:1 CPR cycles
HHM-ERC.2000

23

PROTOCOL FOR EMD (P.E.A)

Ventilate with
high concentration O2
Intubate
IV or IO access
Adrenaline
10 g/kg IV or IO
Fluids
20 ml/kg IV or IO
3 min or
60 X 5:1 CPR
cycles

Adrenaline
100 g/kg IV or IO

HHM-ERC.2000

CONSIDER
Hypovolaemia
Tension pneumothorax
Cardiac tamponade
Drug overdose
Electrolyte imbalance
and treat appropriately

19