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P.A.L.S Pediatric Advanced Life Support Cardiopumonary Arrest Pediatric cardiac arrest Shout for help, Activate emergency response Start CPR •Give oxygen •Attach monitor/defibrillator rhythm Shockable? Yes VF/VT No Asystole /PEA Asystole and Pulseless Electrical Activity Asystole or Pulseless Electrical Activity Asystole / Pulseless Electrical Activity Resume CPR immediately for 2 min IV/IO available: Epinephrin :0.01 mg/kg (0.1 mL/kg of 1:10 000 solution) Repeat every 3 to 5 min No IV/IO: ETT Ephinephrin: 0. 1 mg/kg (0.1 mL/kg of 1:1000 solution) of 1:1000 solution) Consider advanced airway 7 Reversible Causes 6H 5T Hypoxia Tension pneumothorax Hypovolaemia Tamponade Hyper/hypokalaemia Toxins Hypothermia Thrombosis,coronary Hypoglycemia Thrombosis, pulmonary Hydrogen ion (acidosis) Pediatric cardiac arrest Shout for help, Activate emergency response Start CPR •Give oxygen •Attach monitor/defibrillator rhythm Shockable? Yes VF/VT No Asystole /PEA Ventricular Fibrillation/ Pulseless Ventricular Tachycardia Ventricular Tachycardia Rate usually between 100 to 220/bpm, but can be as rapid as 250/bpm P wave obscured if present and are unrelated to the QRS complexes. QRS wide and bizarre morphology Conduction as with pvc Rhythm three or more ventricular beats in a row; may be regular or irregular. Ventricular Fibrillation Ventricular Fibrillation Rate unattainable P wave may be present, but obscured by ventricular waves QRS not apparent Conduction chaotic electrical activity Rhythm chaotic electrical activity Defibrillators • Defibrillators are either manual o automated (AED). • AED can be used for infants and children up to approximately 25 kg (8 years of age). • In infants 1 year of age a manual defibrillator is preferred. Defibrillators • Defibrillators are either manual o automated (AED). • AED can be used for infants and children up to approximately 25 kg (8 years of age). • In infants 1 year of age a manual defibrillator is preferred. Defibrillators • Defibrillators are either manual o automated (AED). • AED can be used for infants and children up to approximately 25 kg (8 years of age). • In infants 1 year of age a manual defibrillator is preferred. Defibrillators Paddle Size Two sizes of hand-held paddle “Adult” size : 8 to 10 cm for children > 10 kg ( approximately 1 year) “Infant” size :4-5 cm for infants < 10 kg Defibrillators Paddle Position: Place over the right side of the upper chest and the apex of the heart (to the left of the nipple over the left lower ribs) so the heart is between the two paddles. Apply firm pressure Defibrillators Interface: • Gel pads, electrode cream or paste, or selfadhesive monitoring-defibrillation pads. • Do not use saline-soaked pads, ultrasound gel, bare paddles, or alcohol pads. Defibrillators Energy Dose: • Initial dose of 2 J/kg • Increase the dose to 4 J/kg • Higher energy levels may be considered, not to exceed 10 J/kg or the adult maximum dose. Pediatric Arrhythmias •Bradycardia •Tachycardia Heart Rate Age Heart Rate (beats/min) Birth–4 wk 1–3 mo 3–6 mo 6–12 mo 130-190 125-185 110-165 105-195 1–3 y 3–5 y 5–8 y 100-155 70-120 60-110 8–12 y 12–16 y 55-100 50-100 Bradycardia • Emergency treatment of bradycardia is indicated when the rhythm results in hemodynamic compromise: • Hypotension • Acutely altered mental status • Signs of shock Atropine • 0.02 mg/kg IV/IO (Repeat once if needed) – Minimum dose: 0.1 mg – Max single dose: 0.5 mg Bradycardia • Pacing is not useful for asystole or bradycardia due to postarrest hypoxic/ ischemic myocardial insult or respiratory failure. Narrow-Complex (<0.09 Second) Tachycardia Supraventricular Tachycardia Rate A rate of >220 beats/min in an infant or >180 beats/min in a child, with a rate out of proportion to clinical status, is likely SVT P wave morphology usually varies from sinus QRS normal (unless associated with aberrant ventricular conduction). Conduction P-R interval depends on the status of AV conduction tissue and atrial rate: may be normal, abnormal, or not measurable. Supraventricular Tachycardia Monitor rhythm during therapy Vagal stimulation: • Infants and young children: apply ice to the face without occluding the airway • older children: carotid sinus massage or Valsalva maneuvers Do not apply pressure to the eye because this can damage the retina. Supraventricular Tachycardia Pharmacologic Cardioversion: Adenosine : The drug of choice. First dose: 0.1 mg/kg (maximum 6 mg) Second dose: 0.2 mg/kg (maximum 12 mg) Verapamil: Effective in older children Dose: 0.1 to 0.3 mg/kg Supraventricular Tachycardia For a patient with SVT unresponsive to vagal maneuvers and adenosine: • Amiodarone 5 mg/kg IO/IV • Procainamide 15 mg/kg IO/IV IF the patient is hemodynamically unstable or if adenosine is ineffective: synchronized cardioversion Start with a dose of 0.5 - 1 J/kg, increase the dose to 2 J/kg. Sinus Tachycardia Rate P wave QRS Conduction Rhythm 101-160/min sinus normal normal regular Sinus Tachycardia • If the rhythm is sinus tachycardia, search for and treat reversible causes.(6 H,5T) Wide-Complex (>0.09 Second) Tachycardia VT Hypotention Hypotension is defined as a systolic blood pressure: 60 mm Hg in term neonates (0 to 28 days) 70 mm Hg in infants (1 month to 12 months) 70 mm Hg (2 age in years) in children 1 to 10 years 90 mm Hg in children 10 years of age Wide-Complex Tachycardia Hemodynamically unstable patients: Synchronized cardioversion 2–4 J/kg up to 10 J/kg Hemodynamically stable patients: • Adenosine :useful in differentiating SVT from VT • Amiodarone :5 mg/kg over 20 to 60 minutes • Procainamide :15 mg/kg given over 30 to 60 minutes QUESTION??? 3 year old child with new-onset seizures, who developed sudden cardiac arrest in the ED Pulseless VT Treatment : Defibrillation First shock: 2 J/kg Second shock: 4 J/kg up to 10 J/kg After one shock: Treatment: • Check monitor lead • Chest compression & CPR immediately • Epinephrine. 5 year old child with cyanosis & agitation Sinus Tachycardia • Search for and treat reversible causes: OT> 40°C Fever is the caues of Sinus Tachycardia and shoud be treated 8 year old child with new-onset palpitation Supraventricular Tachycardia • Hemodynamically stable: – Vagal stimulation – Adenosine • Hemodynamically unstable: – Perform electric synchronized cardioversion Start with a dose of 0.5 - 1 J/kg, increase the dose to 2 J/kg