Advanced Life SupportDr Rasnayaka M MudiyanseMBBS.DCH.MD.MRCP

Use appropriate equipments

Use them as soon as they are available

FluidAdrenalineBicarbonateAmiodoranAntibioticsOxygen

AirwaysOropharangial airwaysIndications GCS < 8 or AVPU < VSize From tragus of the ear to incisor Nasopharangial airwaysBetter toleratedContraindication Suspected fracture base of the skulltSize just fit in to the nostril

Newborn Life SupportOropharyngeal AirwaysResus 28 RC (UK)

Newborn Life Support RC (UK)NLS Spec 4

Newborn Life Support RC (UK)NLS Spec 4

Masks for Oxygen Delivery

Deferent types availableSelect the correct sizeMake sure that there is no air leakTransparent ones are better

Lesson 3: Self-inflating Bag: Basic Parts 2000 AAP/AHA

Bag and MasksEnsure a proper sealShould achieve chest expansion or recovery of the patientAvoid gastric distensionNeck positionCricoid pressureGastric tubeAvoid pneumothorax check blow off valve

Resus 16 RC (UK)

Intubation

NOT FOR IMMEDIATE RESUSCITATIONIndicationsFor continuation of ventilationWhen you have a experienced person and failed air way

Selection of ET Tubes

Size of the ET tube

Just fitting to the nostril no blanchingSize of the small fingerAge ( yrs) /4 + 4Neonates 2.5 kg 2.5 mm 3 kg 3 mm

Length of ET tube

Just up to the black markOral airway - Age ( yrs)/4 + 12 Nasal airway Age(yrs)/4 + 15Neonates 6.5 10 cm

Selection of LaryngoscopeCurved bladeChildren and infants above neonatal ageStrait bladeNeonates

Deferent sizes available

Pre requisites for intubationEquipmentsET Tubes appropriate size + One small and one largeLaryngoscope check whether it is functioningSuckerBags and VentilatorCompetent personPre oxygenationResuscitate with bag and maskAdequate sedation

IntubationVisualize the vocal cords by displacing the tongue to a sideInsert the tube through Vocal cords under direct visionDepth up to the black markHold the tube until it is properly securedCheck whether it is in MistingAir entryRecovery of child

Ventilating a childRateFiO2PIPPEEPI:E ratio

Laryngeal Mask Airway

Advantages of laryngeal mask airway

Allows rapid access Does not require laryngoscope Relaxants not needed Provides airway for spontaneous or controlled ventilation Tolerated at lighter anesthetic planes

Disadvantages of LMADoes not fully protect against aspiration in the non-fasted patient Standard LMA does not allow high positive pressure ventilation Requires re-sterilization

Contra indications for LMA

Greater than 14 to 16 weeks pregnantPatients with multiple or massive injuryMassive thoracic injuryMassive maxillofacial traumaPatients at risk of aspirationNOTE: Not all contraindications are absolute

LMA sizeWeight Inflation volumeSize 1:under 5 kg4 mlSize 1.5:5 to 10 kg7 mlSize 2:10 to 20 kg10 mlSize 2.520 to 30 kg14 mlSize 330 kg to small adult20 mlSize 4adult30 mlSize 5Large adult/poor seal with size 440 ml

CricothyroidotomyOnly when every thing else failed

Pulse Oxymeter

Check the oxygen saturationNo indication about ventilationCheck pulse oxymeter reading while in air to assess respiratory distress

Fluid BolusesFor circulatory failure20 ml/kg of crystalloidRpt 20 ml/kg of crystalloidRpt 20 ml/kg colloidsDengue 10 ml/kg Rpt up to 5

Adrenaline indications and doses

ConditionRouteDoseCardiac arrest Asystole, VF, PEA, VTIV,IO,UV10 micg/Kg ( 0.1 ml/kg of 1 in 10 000 solution)IT100 micg/Kg ( 0.1 ml/kg of 1 in 1 000 solution)Anaphylaxis initial managementIM10 mic/Kg (0.01 ml/kg of 1 in 1000 solution)not responding to IM adrenalineIV infusion0.1 0.3 micg/kg/min increase up to 1 micg/kg/min

For infusions 0.6 ml /kg of adrenaline 1 in 1000 is added to 100 ml of normal saline or 5% dextrose and 1 ml/hour of above solution will deliver 0.1 mcg/kg/min. (Nor- epinephrine also reconstituted same way. The dose of nor epinephrine is 0.1 2 micg/kg/min)Brady cardia not responding oxygenationIV infusionCirculatory failure not responding to fluid boluses and ionotrophsIV infusionsCroupNebulization5 ml of 1 in 1000 solution Can repeat twice with a gap of 30 minuteBronchiolitisNebulization3 ml of 1 in 1000 solution two doses 30 minute apartBronchial asthmaSC/IM0.01 ml/kg 0f 1 in 1000 solution

What to do? Critically ill childSAFE APPROACHABCD1. NO PALPABLE CENTRAL PULSE CARDIAC ARREST2. CENTRAL PULSE PALPABLE CIRCULATORY FAILURE - SHOCK

Initial approach to Cardiac arrestStimulate and assess responseOpen air WayCheck breathingFive breathsCheck pulseChest compression and ventilateAssess rhythmShockableVF/VT algorithmNon ShockableAsystolePEAIf You dont have an ECG machine Manage like Asystole

Cardiac ArrestNo palpable central pulse. Possible causes are ?Asystole

Ventricular fibrillation VF

Pulse less ventricular tachycardia VT

Pulse less electrical activity (Electro mechanical dissociation) EMD

Basic ElectrocardiographyP wave = atrial depolarisation

QRS = ventricular depolarisation (< 0.12 s)

T wave = ventricular repolarisation

Asystole

CARDIAC ARREST - ASYSTOLEAdrenaline 1st 10mcg /kg IV/IO -0.1ml/kg of 1:10,000 solution2nd 10 mcg / kg, IV / IO -0.1-1 ml/kg of 1:10,000 solutionFluid bolusIV Fluid 20 ml/kg Normal saline, may need a second bolus.CPR for 3 minutesRpt Adrenaline every 3-5 mt. (every other loop)

Pulseless Electrical Activity

Pulse less electrical activity

Fluid bolusesAdrenalineTreat the causes H4T4Hypothermia , Hypoxia, Hypoglycaemia, Hyponatriemia

Tension pneumothorax, Thromboembolism, Temponade, Taruma

Ventricular Fibrillation

Ventricular Tachycardia

CARDIAC ARREST VF or Pulseless VT Basic methods ABC Oxygen, CPR1st Shock (4J/kg) ( Australian guidelines 2 j/kg)Consider H4T4 CPR 2 mt. Intubate2nd Shock (4j/kg) CPR 2 mtAdrenaline 10 micg / kg, IV/IO 3rd Shock ( 4j/kg) CPR 2 mtAmiodorane 5 mg/kg 4th Shock CPR Adrenaline 10 micg / kg, IV/IO 5rd Shock ( 4j/kg) CPR 2 mt ( Rpt every other cycle)

Fluid bolus 20 ml/kg

Placing electrode paddlesSize 8-12 cm for child and 4.5 cm for infantsR just below the clavicleL Anterior axillary lineDose 4 j/kgAED attenuated for childrenAdult AED can be used for childrenInfants has not been studied

What to do? Critically ill childSAFE APPROACHABCD1. NO PALPABLE CENTRAL PULSE CARDIAC ARREST2. CENTRAL PULSE PALPABLE CIRCULATORY FAILURE - SHOCK

Palpable Pulse present BUT poor circulation - ShockIf HR less than 60/mt commence CPR with ECMIf HR more than 60/mt Oxygen Fluid bolus Inotropes , Adrenaline, Dopamine, DobutamineTreat the causeConsider sepsis Cefotaxime +/- Fluclox or VancomycinHypoglycaemia 3 -5 ml/kg of 10% dextrose

Thank you

If you dont have a second person available you may find that a Guedel airway is helpful.This is a baby with Pierre Robin sequence. There is a cleft palate but no cleft lip. A naso-pharyngeal airway has been sited which is why the baby breathing without difficulty. This makes the point that, with the airway controlled, even this marked degree of micrognathia is easily manageable. The tongue is displaced from the naso-pharynx by the tube.

This is a baby with Pierre Robin sequence. There is a cleft palate but no cleft lip. A naso-pharyngeal airway has been sited which is why the baby breathing without difficulty. This makes the point that, with the airway controlled, even this marked degree of micrognathia is easily manageable. The tongue is displaced from the naso-pharynx by the tube.

2The picture at the top left will appear first. Point out how the jaw is slack and has flopped backwards the lower lip is at a different level to the upper lip.

When the second picture appears point out how the anaesthetist is pushing the jaw forward. This lifts the jaw and also lifts the tongue out of the oropharynx thus opening the airway.In some cases it is necessary to use both hands to perform a jaw thrust. If you do need to do this then you will need a second person to administer the inflation breaths.