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Pediatric Basic and Advanced


Life Support

Stephen Ludwig, M.D.

CPRIntervention restoring and supporting vital
function after apparent death
The urgent goal is reestablished substrate
delivery metabolic needs of myocardium, brain
and other vital organs
The overall goal is to return the child to society
without morbidity
PALS and APLS have been succesful in the
appropriate resuscitative technique
Early recognition is the most succesful strategy

Pediatric CPR present complexities and

Inadequate prehospital care leads longer
periods of hypoxia and hypoperfusion
Established IV line is the common frustation
intraosseousand central line
The most common cardiac rhythms to be
recognized and managed are sinus bradycardia,
SVT, asystolebeware congenital heart disease

The outlook for survival after CPR is very good for

pediatric patient if the arrest recognized rapidly
and managed skillfully

If patient come to ER in asystole or with

inadequate prehospital resuscitation will have
poor prognosis
Lack of Oxygen/Glucose
Substrat SKIN CNS Cardiovascular Abdominal Renal
Deprivation organ
Pallor Irritability Tachycardia Dismotility Decreased
Cool skin Urine output

mottling confusion capillary resistance ileus oliguria

pulses response to cardiac failure third spacing Anuria

voice to pain fluids
Poor capillary seizure
Refill Bowel Slough
Coma Asystole
Evaluation Management option
CNS shout or apply painful stimuli
no response
Airway if not patent jaw lift
patent jaw thrust
oropharyngeal airway
nasopharyngeal airway
Breathing tracheal tube
yes no Mouth to mask
Supplemental o2, mouth to tracheal tube
nassal canulas, nasal resuscitator to mask
cath, face mask resuscitator to tracheal tube
rescue breathing 12-24/min
Cardiac output no External cardiac compression
yes vent: 1 breath/ 5 compression
ECG: HR, rhythm ECG monitor
Monitor Pulse oxymeter Drug & vol management
specific therapy
Lab: Dextrostik, BGA, SE, BUN

3 basic sequences of evaluation and

management for brain hypoxia
1. Airway is maneuvered to move the mandibular
block of tissue up and off the posterior
pharyngeal wall
2. Watch the chest wall for any breathing
3. Evaluated the circulation by feeling for arterial
Look listen and feel the gas exchange
Look the chest, listen the mouth and nose, feel
with the cheek for air movement

Traumastabilized head and cervical spine
Mandibular block because tissue falling posteriorly,
lying in posterior hypopharynx
Head tilt and chin lift
Oropharyngeal airways used when manual
manipulation of the airway cannot maintain airway
The purpose is to stent mandibular block of tissue off of
the pharyngeal posterior
1. To hold the tongue away from the posterior pharyngeal
2. Provide air channel the mouth
Prepare active suction for the saliva
The proper size estimated by placing the airway alongside
the face so the bite block portion parallel to the palate
Nasopharyngeal Airways

To stent the tounge from posterior pharyngeal

The length is measured by distance from nares to
the ear
It placed between the tounge and the posterior
pharyngeal wall
Adenoidal hypertrophy and bleeding diatheses are
contraindications because it may lacerate the
vascular adenoidal tissue
Endotracheal tube
to supply a stable alternate airway
It is used to:
1. Overcome upper airway obstruction
2. Isolate the larynx from the pharynx
3. Allow mechanical asiration of secretions from tracheal
bronchial tree
4. Facilitate mechanical ventilation
The best positions of the tip of the tube is in midtracheal
position that can be check by radiological imaging or
Laryngoscope helped Insertion of the tube
Evaluate the breathing by observing free uniform
expansion of the lower chest and upper
abdomen (if adult is upper chest)
1. Listen the gas exchange through the trachea
2. Listen bilateral breath sound to assess
peripheral aeration and symmetric lung
Oxygen delivery devices
Nasal canule
100% humidified O2 delivered through the hollow, the
final O2 delivery 30-40% because entrainment of air
It is best tolerated by older child
Oxygen hoods (head box)
to maintain controlled environment for O2, humidity,
and temperaturebest for infant&newborn
It can deliver 80-90% oxygen
Beware of the toxic to the eyes or lungs of infant
Oxygen Tent
to provide a controlled and stable environment for
humidity, temperature and oxygendeliver 21-50%
Thight fit and only necessary entry should be
allowed because effect O2 concentration
O2 Masks
used for spontaneously breathing patient thereare
use for delivery 100% O2
Beware if the patient is vomiting can become
Assisted Ventilation
It is performed when airway has been
established and the child is not breathing
spontaneously or gas exchange is not adequate
Mouth to mouth is no longer recommended
because risk of HIV
Expired air technique
for gas to flow the bag must be squeezed,
should avoid units without oxygen reservoir
adaptation because deliver low concentrations
of supplemental O2
As with the other components of CPR, the
circulation must be first assessed and then
Evaluate the effectiveness of circulation :
1. Observing skin and mucous membrane color
2. Palpating a peripheral pulse and checking
capillary refill
The palpation of a strong femoral or brachial
pulse indicates presumptively that the cardiac
output is adequate

Blood pressure measurements will help quantify

the effectiveness of cardiac function

Management may be divided into five phases:

1. cardiac compression,
2. establishment of an intravascular route,
3. use of primary drugs,
4. use of secondary drugs, and
5. defibrillation.

cardiac compression (CC) to establish at least a

minimum circulation to the brain.
compress directly over the ventricles that were
believed to be located under the middle one-
third of a child's sternum
The depth and rate of compression are based
on the child's age
Compression should be smooth, continuous,
and uninterrupted
The resultant wedge-shaped dead space
beneath the upper thorax may absorb the force
of compression
Compressions may then be
applied with one or two
fingers in the infant or with
one hand in the older child.
When using the technique
developed by Thaler, the
rescuer links his or her
fingers beneath the thoracic
spine and compresses with
the thumbs
Intravenous Lines

When possible, a short, large-gauge intravenous

line should be obtained.
Peripheral sites are an acceptable choice and
may be readily available.
Central lines are useful for getting drugs and a
large volume of fluids into the central circulation.
Intraosseous (into the bone) infusion is an old
technique that has been revived and widely
The cannulation of the subclavian vessel may
also be difficult and associated with
pneumothorax and hemothorax.
Three vessels that are easily cannulated and
give access to the central circulation are the
femoral, internal jugular, and external jugular
Primary Drugs

The primary drugs for advanced life support are

oxygen, epinephrine, sodium bicarbonate,
atropine, and glucose
Our recommended drug dosages are based on
kilograms of body weight.

A fundamental goal of basic and advanced life

support is to correct cerebral and myocardial
hypoxia before irreversible injury occurs.
Oxygen is indicated for any patient who is
having decreased oxygen delivery to the tissues
Any patient who is even suspected to be
hypoxemic should be given oxygen.

Epinephrine actions include and adrenergic

The primary effect is vasoconstriction and a resultant
increase in systolic and diastolic blood pressure.
The adrenergic action of the drug is also beneficial in
producing an increased inotropic (contractile force) and
chronotropic (cardiac rate) effect. In addition, the b effect
produces vasodilation of the coronary and cerebral
All of these actions are beneficial to the resuscitative
Indications include asystole, symptomatic
bradycardia, and hypotension not related to
volume depletion.
Also used to try to change a fine fibrillation pattern
to a coarse one before a defibrillation attempt
The recommended initial dose of epinephrine is
10 g/kg IV.
Recently, current epinephrine dose
recommendations and have used doses 10 to 20
times greater (i.e., 0.1 to 0.2 mg/kg)
Sodium Bicarbonate

With the onset of respiratory failure, the patient develops

respiratory acidosis.
Rising levels of carbon dioxide in the blood produce a fall
in pH.
The immediate treatment for this type of acidosis is
adequate ventilation.
As the patient's circulation begins to fail, there is
production of lactic acid and a metabolic acidosis.
Sodium bicarbonate corrects the metabolic acidosis by
combining with hydrogen to form carbon dioxide and water.
This additional production of carbon dioxide must also be
eliminated through ventilation.

The indication for atropine is bradycardia

associated with
premature ventricular ectopic beats, or
myocardial perfusion

Glucose should be considered a primary drug.

Infants have minimal glycogen stores for rapid
conversion to glucose
The dose of glucose is 0.5 to 1.0 g/kg IV. Either
a 10% or a 25% solution may be used.
Untoward effects include hyperglycemia and
hyperosmolality, but these should not occur if
the initial dose of glucose is based on a
documented need
Secondary Drugs

Dopamine is indicated for the patient with

hypotension and inadequate renal perfusion.
The dosage of dopamine is 10 g/kg per minute,
which is within the range for desired cardiac

Dopamine is a precursor of epinephrine. It acts

on both and adrenergic receptors.
Dopamine has a unique dopaminergic effect
that increases blood flow to renal and
mesenteric blood vessels
Effect occurs over the low-dose range, 2 to 10
/kg per minute.
The cardiac actions of dopamine are similar to
those of epinephrine and include a positive
inotropic and chronotropic effect.

The possible clinical indications for the use of steroids

include adrenal insufficiency
current recommendations dose include
methylprednisolone 30 mg/kg IV, or dexamethasone 1
mg/kg IV.
The adverse reactions with short-term administration are
There may be worsening of hyperglycemia and retention
of sodium and water.
The worsening of a bacterial infection is a theoretical risk
that should not inhibit the short-term use of steroids in a
life-threatening situation.
Once resuscitation efforts have achieved
cardiorespiratory stability, the patient should be
transported to an inpatient special care unit for
the critically ill.
Direct effects include patient discomfort, pain,
and the physical stimulation of movement.
Indirect effects include lack of equipment and
facilities and the limitations that occur by being
in motion
If the heart and supporting technology applied to
it cannot sustain brain function, resuscitative
effort should be discontinued.
There is growing evidence that if the cardiac
muscle is not responsive to the first three doses
of epinephrine in the state of adequate
oxygenation and ventilation, there is no hope for
a successful resuscitation.
Respiratory functions are easily supported
mechanically and therefore are not used as
markers for continuation or discontinuation of
Brain death is becoming widely accepted as the
ultimate determinant of death
The key concept is to monitor the effects of the
hypoxic state on the cerebral nervous system
and to discover what can be done to minimize or
reverse these effects
The mechanism for this injury is through ion-
dependent lipid peroxidation.
In the future, cerebral resuscitation may be
aimed at reducing lipid peroxidation and iron
release during the reperfusion phase following
Other new approaches have centered on
methods of increasing blood flow, so-called new
The techniques have been used to attempt
simultaneous chest compression and ventilation
to increase ventilatory flow rates and longer
systolic compression times.