Autism Genetics

Pediatric Resuscitation

Pediatric Cardiac Arrest

Usually secondary to respiratory failure or arrest

Most Important Intervention

Adequate oxygenation, ventilation

Basic Life Support

Airway• Head-tilt/chin-lift method• Big tongue; Forward jaw displacement critical• Avoid extreme hyperextension• With possible neck injury, jaw thrust

Basic Life Support

Breathing• Look-Listen-Feel• Limit to volume causing chest rise• Children usually underventilated!• Use BVM only if proficient• Pedi BVM’s should not have pop-off valves

Basic Life Support

Breathing• Do NOT use demand valve on children• Ventilate infants, children every 3 seconds

Basic Life Support

Circulation• Infants: brachial• Children: carotid

Basic Life Support

Circulation• Infant chest compressions – 2 fingers– 1 finger width below nipple line– 1/2 - 1 inches–At least 100/minute

Basic Life Support

Circulation• Child chest compressions–One hand– Lower half of sternum – 1 - 1.5 inches– 100/minute

Basic Life Support

Circulation• Child CPR–Maintain continuous head tilt with hand on

forehead–Perform chin lift with other hand while

ventilating

Best Sign of Effective Ventilation

Chest Rise

Best Sign of Effective Circulation

Pulse with Each Compression

Oxygen Therapy

Initiate ASAP Do not delay BLS to obtain oxygen

Oxygen Therapy

Use highest possible FiO2

• No risk in short term100% O2

Humidify if possible• Avoids plugging airways, adjuncts

Endotracheal Intubation

Need to intubate is not same as need to ventilate!


Proper tube size• Same size as child’s little finger• Child > 1 year: [(Age + 16 ) / 4]


Children < 8 years old• Small tracheal diameter• Narrow cricoid ring• Uncuffed tubes

Infants, small children• Narrow, soft epiglottis• Straight blade


Attempts not >30 seconds Bradycardia: oxygenate, ventilate


Avoid hyperextension Use “sniffing position” Lift up; do not pry back


Confirm placement by:• Seeing tube go through cords• Chest rise• Equal breath sounds• No sounds over epigastrium

• CO2 in exhaled air


Mark tube at corner of mouth Avoid excessive head movement Frequently reassess breath sounds Ventilate to cause gentle chest rise

Endotracheal Drugs

Epinephrine, atropine, lidocaine


Drug administration• Do not delay while attempting IV access• Dilute with normal saline• Stop compressions• Inject through catheter passed beyond ETT• Follow 10 rapid ventilations

Cricothyrotomy

Surgical contraindicated in children <12 Narrowing of trachea at cricoid ring makes

procedure hazardous Use needle technique only

Vascular Access

Same reasons as adults• Drugs• Fluids

Scalp Veins

No value in cardiac arrest Useful in infants < 1 year old for

maintenance fluids, drug route

Scalp Veins

Rubber band for tourniquet 21, 23 gauge butterfly Attach syringe, flush needle before

inserting

Scalp Veins

Point needle in direction of blood flow Leave syringe attached, inject 1cc saline

after entering vein to check infiltration

Hand, Arm, Foot Veins

22 gauge catheter for smaller children Restrain extremity before attempting Incise overlying skin with 19 gauge needle Flush needle as with scalp vein technique

External Jugular Life-threatening situations only 22 gauge catheter Restrain by wrapping in sheet Extend head over end of table, rotate 900

If vein perforates, do not go to other side• Risk of paratracheal hematoma, airway

obstruction

Prevention of Fluid Overload

Avoid using bags over 250cc Use mini-drip sets, Volutrols Fluid resuscitation: 20cc/kg boluses

Intraosseous Cannulation

Placement of cannula into long bone intramedullary canal (marrow space)


Indication• Vascular access required• Peripheral site cannot be obtained– In two attempts, or–After 90 seconds


Devices• 16 gauge hypodermic needle • Spinal needle with stylet• Bone marrow needle (preferred)


Site• Anterior tibia• 1 - 3 cm below knee • Medial to tibial tuberosity


Contraindications• Fractures• Osteogenesis imperfecta• Osteoporosis• Failed attempt on same bone


Needle in place if:• Lack of resistance felt• Needle stands without support• Bone marrow aspirated• Infusion flows freely

What can be put thru an IO?

Anything that can be put through an IV!

Remember…….

You don’t need a line to give drugs during a code.

Epinephrine, atropine, lidocaine can go down tube

Defibrillation

90% of pediatric cardiac arrest is• Asystole, or • Bradycardic PEA

Defibrillation seldom needed

Defibrillation

Pediatric VF suggests• Electrolyte imbalances• Drug toxicity• Electrical injury

Defibrillation

Paddle diameter:• Infants: 4.5 cm• Children: 8.0 cm

Largest paddles that contact entire chest wall without touching

If pediatric paddles unavailable, use adult paddles with A-P placement

Defibrillation

Energy Settings• Initial: 2 J/kg• Repeat: 4 J/kg

Cardioversion

Cardiovert only if signs of decreased perfusion

Energy settings:• Initial: 0.5 - 1.0 J/kg• Repeat: 2.0 J/kg

Cardioversion

Narrow-complex tachycardia, rate < 200• Usually sinus tachycardia• Look for treatable underlying cause• Do not cardiovert

Cardioversion

Narrow-complex tachycardia, rate > 230• Usually supraventricular tachycardia• Frequently associated with congenital

conduction abnormalities

Cardioversion

Narrow-complex tachycardia, rate > 230• If hemodynamically stable, transport• Adenosine may be considered

Cardioversion

Narrow-complex tachycardia, rate > 230• If hemodynamically unstable, cardiovert• If no conversion after two shocks, consider

possibility rhythm is sinus tachycardia

Drug Therapy

Epinephrine• Asystole, bradycardia PEA• Stimulates electrical/mechanical activity

Drug Therapy

Epinephrine Dosage• IV or IO: 0.01 mg/kg 1:10,000• ET: 0.1 mg/kg 1:1000

Drug Therapy

Atropine• 0.02 mg/kg IV or IO–Double ET dose

• Minimum dose: 0.1 mg to avoid paradoxical bradycardia

• Maximum single dose: –Child: 0.5 mg–Adolescent: 1mg

Drug Therapy

Most bradycardias respond to• Oxygen• Ventilation

For bradycardia 2o to hypoxia/ischemia, preferred first drug is epinephrine

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Autism Genetics