Transcript Pediatric Advanced Life Support

Pediatric
Advanced
Life Support
Introduction

PALS Is Designed To Give The Student The Ability
To Assess & Quickly Respond To Pediatric
Emergencies Including Respiratory Arrest And
Cardiac Arrest.

The Course Is Two Days In Length And
Encompasses A Written Exam And A Core
Scenario That Must Be Passed With At Least An
84%. First Hour Of Class We Will Be Going Over A
Pre-test.
Corse Overview
PALS Over View: AHA
Guidelines
Purpose of PALS

Acquire The Ability To Recognize An Infant/Child Whom Requires Advanced Life
Support

Learn To Apply The “Assess, Categorize, Decide And Act” Model Of Assessment

Learn The Importance And Technique For Quality And Effective CPR And ALS

Learn Effective Team Coordination And Team Member Roles In Resuscitation
Key Points Of Importance Of PALS

The First Step In Cardiac Arrest Is Prevention

If Cardiac Arrest Does Occur, Effective High Quality CPR Is The Most Important
Aspect In Successful Resuscitation

Studies Show That Poor Skills By Healthcare Workers Lead To Increased Incidences
Of Death And Brain Death

All PALS Students Must Perform Effective And Quality CPR Throughout The Course
Overview Of PALS Science
New 1-Rescuer and
Multiple Rescuer CPR

Single rescuers are now encouraged to use cell
phones with speaker capability while attending
the victim. They no longer need to leave to get
help

Chest compression depth remains at 1/3 AP
diameter for pediatrics less than 1 year and up to
1.5-2 inches for children, and no more than 6 cm
in adolecents

CPR rate is no 100 up to 120/min
New 2016 Updates

In specific settings, when treating pediatric
patients with febrile illness, the use of restrictive
volumes of isotonic crystalloid leads to improved
survival.

This contrasts with traditional thinking that routine
aggressive volume resuscitation is beneficial
New 2016 Updates

Routine use of Atropine as a premedication for
emergency tracheal intubation in non-neonates,
specifically to prevent arrhythmias
(bradyarrhythmias), is controversial. Also, there are
data to suggest that there is no minimum dose
required for this indication
New 2016 Updates

If invasive arterial blood pressure monitoring (Aline) is already in place, it may be used to adjust
CPR to achieve specific blood pressure targets for
children in cardiac arrest.
New 2016 Updates

Amiodarone or Lidocaine is an acceptable
antiarrhythmic agent for refractory pediatric VF
and pVT in children (previously Lidocaine was
thought to be ineffective)

Epinephrine continues to be recommended as a
vasopressor in pediatric cardiac arrest

For pediatric patients with cardiac diagnosis of
IHCA in settings with existing ECMO protocols,
ECPR may be considered.

(isocapnic hyperventilation with cold air)
New 2016 Updates

Fever should be avoided when caring for
comatose children with ROSC after OHCA.

A large randomized trial of therapeutic
hypothermia for children with Out of Hospital
Cardiac Arrest, showed no difference in
outcomes whether a period of moderate
therapeutic hypothermia (temp 32-34C) or the
strict maintenance of normothermia (temp 3637.5C) was provided
New 2016 Updates

Several intra-arrest and post-cardiac arrest clinical
variables were examined for prognostic
significance.

No single variable was identified to be sufficiently
reliable to predict outcomes.

Therefore, caretakers should consider multiple
factors in trying to predict outcomes during
cardiac arrest and in the post-ROSC setting

After ROSC, fluids and vasoactive infusions should
be used to maintain a systolic blood pressure
above the fifth percentile of age
New 2016 Updates

After ROSC, normoxemia should be targeted.
When the necessary equipment is available, O2
administration should be weaned to target an
O2Hb of 94-99%

Hypoxemia should be strictly avoided. Ideally, O2
should be titrated to a value appropriate to the
specific condition

After ROSC, PaCO2 should target appropriate to
each patients condition. Exposure to severe hyper
or hypo capnia should be avoided
BLS

If There's A Palpable Pulse >60, But The Patient Shows Inadequate
Breathing, Give Rescue Breaths At A Rate Of 12–20 Breaths/Minute
(One Breath Every Three To Five Seconds) Using The Higher Rate For
Younger Children

If The Pulse Is <60 And There Are Signs Of Poor Perfusion (Pallor,
Mottling, Cyanosis) Despite Support Of Oxygenation And Ventilation,
Begin Chest Compressions. Beginning CPR Prior To Full Cardiac Arrest
Results In Improved Survival.

Place Less Emphasis On The Pulse Check. For An Unresponsive And
Non-breathing Child, Begin CPR If A Pulse Cannot Be Detected Within
10 Seconds
BLS

Initiate CPR With Chest Compressions Rather Than Rescue Breaths (CAB
Rather Than ABC). Asphyxial Cardiac Arrest Is More Common In Infants
And Children, And Ventilations Are Extremely Important In Pediatric
Resuscitation.

The CAB Sequence For Infants And Children Is To Simplify Training.
Therefore, Start CPR With Chest Compressions Immediately, While A
Second Rescuer Prepares To Provide Ventilation

Compress At A Rate Of At Least 100/Min up to 120. After Each
Compression, Allow The Chest To Recoil Completely

Depth Of Compressions Is At Least One-third (1/3) The Anterior-posterior
Diameter Of The Chest Or Approximately 1½ Inches (4 Cm) In Infants And
2 Inches (5 Cm) In Children up to 6cm. Note: Inadequate Compression
Depth And Incomplete Recoil Is Common Even Among Trained Providers.
BLS

For The Lone Rescuer, A Compression-ventilation Ratio Of 30:2 Is
Recommended. For Two Rescuers, A Ratio Of 15:2 Is Recommended.

Oropharyngeal And Nasopharyngeal Airways Help Maintain An Open
Airway. Make Sure To Select The Correct Size.

Deliver Ventilations With As Short A Pause In Compressions As Possible.
If An Advanced Airway Is In Place, Compressions Should Be Delivered
Without Pauses For Ventilation.

Ventilations Should Be Delivered At A Rate Of Eight To Ten
Breaths/Minute (Every Six To Seven Seconds) Without Interrupting
Compressions. Avoid Excessive Ventilation
DEFIBRILATION

Follow Package Directions For Placement Of Defibrillator Pads. Place
Manual Electrodes Over The Right Side Of Upper Chest And The Apex
Of The Heart (To Left Of Nipple Over Left Lower Ribs). There Is No
Advantage In An Anterior-posterior Position Of The Paddles.

Paddle Size: Use The Largest Electrodes That Will Fit On The Childʼs
Chest Without Touching, Leaving About 3 Cm Between Electrodes.
“Adult” Size (8–10 Cm) Electrodes Should Be Used For Children >10 Kg
(Approximately One Year). “Infant” Size Should Be Used For Infants
<10 Kg.

An Initial Dose Of 2 To 4 J/Kg Is Acceptable. For Refractory VF, It Is
Reasonable To Increase The Dose To 4 J/Kg. Higher Energy Levels May
Be Considered, Not To Exceed 10 J/Kg Or The Adult Maximum Dose
DEFIBRILATION

If An AED With An Attenuator Is Not Available, Use An AED With
Standard Electrodes

In Infants <1 Year, A Manual Defibrillator Is Preferred

If Not Available, An AED With An Attenuator May Be Used

An AED Without A Dose Attenuator May Be Used
If Neither A Manual Defibrillator Nor A Dose Attenuator Is Available
CPR Highlights

The PALS Cardiac Arrest Algorithm Is Simplified And Organized Around
Two-minute Periods Of Uninterrupted CPR.

Exhaled Co2 Detection Is Recommended As Confirmation Of
Tracheal Tube Position With A Perfusing Rhythm In All Settings And
During Intra- Or Inter-hospital Transport.

Capnography/Capnometry, Used For Confirming Proper
Endotracheal Tube Position, May Also Be Useful To Assess And
Optimize The Quality Of Chest Compressions During CPR

May Also Spare The Rescuer From Interrupting Chest Compressions For
A Pulse Check Because An Abrupt And Sustained Rise In Petco2 Is
Observed Just Prior To Clinical Identification Of Return Of
Spontaneous Circulation. (ROSC)
CPR Highlights

Upon ROSC, Titrate Inspired Oxygen (When Oximetry Is Available) To
Maintain SPo2 >94%-99% To Limit The Risk Of Hyperoxemia.

Bradycardia With Pulse And Poor Perfusion
1.
Epinephrine
2.
Atropine
3.

Pacing May Be Used
Tachycardia With Pulse And Poor Perfusion, Narrow Complex (QRS
<0.09) SVT
1.
Attempt Vagal Stimulation
2.
Adenosine Is The Drug Of Choice

If Hemodynamically Unstable Or Adenosine Are Ineffective
1.
Perform Synch Cardioversion, Starting At A Dose Of 0.5 To 1 J/Kg,
2.
Increasing To 2 J/Kg
CPR Highlights






1.
2.
3.
4.

1.
Wide Complex (QRS>0.09) Tachycardia, Hemodynamically Stable
Adenosine May Be Considered If The Rhythm Is Regular And
Monomorphic And Is Useful To Differentiate SVT From VT
Consider Cardioversion Using Energy Described For SVT
Expert Consultation Is Strongly Recommended Prior To Administration Of
Amiodarone Or Procainamide
If Hemodynamically Unstable, Cardioversion Is Recommended.
SVT
Stable
Vagals First
Adenosine 0.1, 0.2mg/Kg
Then Cardiovert As Last Resort 0.5-1J/Kg
Unstable
Cardiovert
CPR Highlights

VT With Pulse

Stable
1.
Adenosine .1 .2,
2.
Amiodarone 5mg/Kg Over 60 Min
3.

1.
Cardioversion If Needed
Unstable
Cardioversion
V-Fib Or V-Tach With No Pulse
1.
Defib Asap
2.
CPR
3.
Epi .01/kg
4.
After Third Shock Amiodarone
Other information

Routine Calcium Administration Is Not Recommended For Pediatric
Cardiopulmonary Arrest In The Absence Of Documented Hypocalcemia, Calcium
Channel Blocker Overdose, Hypermagnesemia Or Hyperkalemia.

Etomidate Has Been Shown To Facilitate Endotracheal Intubation In Infants And
Children With Minimal Hemodynamic Effect

Etomidate Is Not Recommended For Routine Use In Pediatric Patients With
Evidence Of Septic Shock.

Although There Have Been No Published Results Of Prospective Randomized
Pediatric Trials Of Therapeutic Hypothermia, Based On Adult Evidence,
Therapeutic Hypothermia (To 32–34°c) May Be Beneficial For Adolescents Who
Remain Comatose After Resuscitation From Sudden, Witnessed, Out-of-hospital Vf
Cardiac Arrest.

Therapeutic Hypothermia (To 32–34°C) May Also Be Considered For Infants And
Children Who Remain Comatose After Resuscitation From Cardiac Arrest.

Whenever Possible, Provide Family Members With The Option Of Being Present
During Resuscitation Of An Infant Or Child.
Break Time 15 Min…
CPR Practice and
Competency Testing

Single Person Resuscitation (30:2 Ratio, 100 Compressions A Minute, 2
Minute Cycles)

Two Person Resuscitation (15:2 Ratio)

Use Of Bag/Mask (Remember, Always Bag A Patient Whom Becomes
Distressed And Cyanotic On The Ventilator)
CPR Practice and
Competency Testing

Compression techniques (one hand method, two hand, two
finger or encircling thumb technique)
BLS Testing
Overview of PALS CPR

High Quality CPR

Compression Rate Of At Least 100 Per Minute

Push Hard And Fast

Compression Depth 1/3 AP Diameter Of The Chest, 1 ½
Inches In Infants And 2 Inches In Pediatrics

Allow Proper Chest Recoil After Each Compression To Allow
For Proper Cardiac Output

Minimize Interruptions For Continuous Brain And Organ
Perfusion (10 Sec Or Less, Back On The Chest)

Avoid Excessive Ventilation To Prevent Impendence Of
Venous Return Back To The Heart And Gastric Insufflation
Overview of PALS CPR

AED Paddle Size

Use The Largest Electrodes That Will Fit On The Childʼs Chest
Without Touching, Leaving About 3 Cm Between Electrodes.

Adult Size (8–10 Cm) Electrodes Should Be Used For Children
>10 Kg (Approximately One Year).

Infant Size Should Be Used For Infants <10 Kg.

If An AED With An Attenuator Is Not Available, Use An AED With
Standard Electrodes

In Infants <1 Year, A Manual Defibrillator Is Preferred. If Not
Available, An AED With An Attenuator May Be Used.

An AED Without A Dose Attenuator May Be Used If Neither A
Manual Defibrillator Nor A Dose Attenuator Is Available
Management Of Respiratory
Emergencies
AIRWAY MANAGMENT

Upper Airway Obstruction:

Note Presence Of Stridor (Typically Inspiratory)

Note Cough (Seal Like, Dull, Muffled)

Note Consciousness

Note Breath Sounds (Decreased?), Note HR (Typically Tachycardia)

Note Color, Retractions, Grunting, Tachypnea And WOB

If In Distress Causing Compromise
1.
2.
3.
Open Airway And Determine If An Advanced Airway Is Needed
Support Ventilations And Begin
CPR As Needed

Possible Causes: Croup, Epiglottitis, Aspiration, Inhaled Toxins, Anaphylaxis

Administer Nebulized Epinephrine/Racemic For Moderate Stridor/Barking
Cough

Treat Underlying Problem: Airway, Cool Mist, Racemic Epinephrine, Decadron,
Steroids
AIRWAY MANAGMENT
Lower Airway Obstruction

Note Presence Of Wheezing (Typically Expiratory), Prolonged
Expiratory Phase And Air trapping

Note Decreased Aeration In Lungs, Desaturation

Note Color (Cyanosis Is A Late Sign)

Causes
1.
Asthma
2.
Pneumonia
3.
Bronchiolitis
4.

Aspiration That Has Migrated Passed Trachea (Unilateral Wheezing)
Treat With Bronchodilators, Bronchial Hygiene And Bronchoscopy
Advanced Airways

Airway Problems In The Pediatric Population Is Especially Critical As It
Typically Is The Precipitating Cause Of Pediatric Arrest
Advanced Airways

Cuffed ETT Now Considered As Safe Or More Safe Than A Non Cuffed For
Small Children

Verify Placement
1.
Exhaled CO2 Detector (Turns Yellow For Correct Placement)
2.
Check Chest Rise
3.
Breath Sounds
4.
CXR

Exhaled CO2 May Not Be Detected In Prolonged Arrest

USE DOPE Mnemonic When Determining Deterioration Of An Intubated
Patient;

D Displacement Of ETT

O Obstruction Of The Tube

P Pneumothorax

E Equipment Failure
Support of Ventilation

The Method Of Advanced Airway Support Include
1.
Endotracheal Intubation
2.
Laryngeal Mask
3.
Bag-mask
Method Provided To The Patient Should Be Selected On The Basis Of The
Training And Skill Level Of Providers In A Given Advanced Life Support
(ALS) System And On The Arrest Characteristics And Circumstances (Eg,
Transport Time And Perhaps The Cause Of The Arrest).
Split Up Into Two Groups

Group 1

Group 2

CPR Practice

Intubation Practice

LMA Overview
1.
Bag And Mask Practice
2.
AED Practice
3.
Oxygen Management
20 Minutes Per Group Then Switch
Airway Management
Watch Airway Management Video
Rapid Sequence Intubation

To Facilitate Emergency Intubation And Reduce The Incidence Of
Complications, Skilled, Experienced Providers May Use Sedatives,
Neuromuscular Blocking Agents, And Other Medications To Rapidly
Sedate And Paralyze The Victim.

Use RSI Only If You Are Trained And Have Experience Using These
Medications And Are Proficient In The Evaluation And Management
Of The Pediatric Airway.

If You Use RSI You Must Have A Secondary Plan To Manage The
Airway In The Event That You Cannot Achieve Intubation.
Airway Management
Cuffed Versus Uncuffed Tubes
 In The In-hospital Setting A Cuffed Endotracheal Tube Is As Safe As An
Uncuffed Tube For Infants Beyond The Newborn Period And In
Children.
 In Certain Circumstances (Eg, Poor Lung Compliance, High Airway
Resistance, Or A Large Glottic Air Leak) A Cuffed Tube May Be
Preferable Provided That Attention Is Paid To Endotracheal Tube Size,
Position, And Cuff Inflation Pressure
Disordered Control Of Breathing
 Occurs Often After A Head Injury Or As A Result Of Aneurysm Or
Infection In Brain. Normal Rhythmic Breathing Is Altered, Requires
Protection Of Airway With Artificial Airways.
Endotracheal Tube Size
 Length-based Resuscitation Tapes Are Helpful And More Accurate
Than Age-based Formula Estimates Of Endotracheal Tube Size For
Children Up To Approximately 35 Kg, Even For Children With Short
Stature.
Airway Management

In Preparation For Intubation With Either A Cuffed Or An Uncuffed
Endotracheal Tube, Confirm That Tubes With An Internal Diameter (ID)
0.5 Mm Smaller And 0.5 Mm Larger Than The Estimated Size Are
Available.

During Intubation, If The Endotracheal Tube Meets Resistance, Place
A Tube 0.5 Mm Smaller Instead.

Following Intubation, If There Is A Large Glottic Air Leak That Interferes
With Oxygenation Or Ventilation, Consider Replacing The Tube With
One That Is 0.5 Mm Larger

Or Place A Cuffed Tube Of The Same Size If An Uncuffed Tube Was
Used Originally.

Note That Replacement Of A Functional Endotracheal Tube Is
Associated With Risk; The Procedure Should Be Undertaken In An
Appropriate Setting By Experienced Personnel.
Airway Management

If An Uncuffed Endotracheal Tube Is Used For Emergency Intubation,
It Is Reasonable To Select
1.
3.5-mm ID Tube For Infants Up To One Year Of Age And A
2.
4.0-mm ID Tube For Patients Between 1 And 2 Years Of Age.
3.
After Age 2, Uncuffed Endotracheal Tube Size Can Be Estimated By The
Following Formula: Uncuffed ET Tube=4+Age/4

If An Cuffed Endotracheal Tube Is Used For Emergency Intubation, It Is
Reasonable To Select
1.
3.0 Mm ID Tube 1 Year Of Age
2.
3.5 Mm ID Tube For Children Between 1 And 2 Years Of Age
3.
After Age 2, Cuffed Endotracheal Tube Size Can Be Estimated By The
Following Formula: Cuffed ET Tube=3.5+Age/4
Respiratory Compromise

Be Vigilant For Signs Of Respiratory Compromise. Often, Symptoms Of
Shock Or Cardiac Distress Are Treated Without Regard To Respiratory
Status, But In Many Cases A Cardiac Dysrhythmia Or Compensated
Shock Can Be Completely Resolved By Aggressive Oxygenation.

Whenever A Pediatric Patient’s Heart Rate Is Too Slow, Or Is Slowing, The
First And Primary Treatment Is To Give Assisted Ventilations If The Child’s
Airway Is Not Maintained Or Their Work Of Breathing Is Not Effective.

For Pediatric Patients With Any Symptoms, Always Provide Oxygen, The
Exact Flow Rate Depending On Patient Needs.

Stable Patients With A Cardiac Dysrhythmia But No Respiratory Distress
Can Receive Low-flow Oxygen (Up To 4 L/Min.) Via Nasal Cannula.

Unstable Cardiac Patients, Patients In Shock (Compensated Or
Hypovolemic), Or Patients With Respiratory Distress Should Receive
Oxygen Via Non-rebreather Mask, If They Tolerate It.

Patients In Respiratory Failure Should Receive Assisted Ventilations Via
Bag-mask Valve.
Respiratory Compromise

It Is Critical That Students Correctly Categorize The Degree Of
Respiratory Compromise And Provide Appropriate Oxygenation.

In Respiratory Distress, The Patient Will Have An Increased Respiratory
Rate And Effort.

Be Alert For Patient Position, Nasal Flaring, Retractions, And Accessory
Muscle Use.

Skin Color May Be Normal Or Pale, And The Patient May Exhibit The
Beginnings Of An Altered Level Of Consciousness (Aloc).

Adventitious Breath Sounds May Or May Not Be Present.

Any Patient In Respiratory Distress Should Receive High-flow Oxygen
Via Non-rebreather Mask, If They Tolerate It.
Respiratory Compromise

In Respiratory Failure

The Patient May Have An Increase In Respiratory Effort With Increased
Or Decreased Respiratory Rate.

Head Bobbing, Decreased Respiratory Effort, “Seesaw” Respiratory
Pattern, Shallow Respirations, Cyanosis, Difficulty Speaking, And Poor
Air Movement (Diminished Or Absent Breath Sounds) Are Signs Of
Respiratory Failure.

For Any Child In Respiratory Failure Or Severe Respiratory Distress, You
Should Consider The Following Interventions
1.
Assisted Ventilations (Provide Ventilations Via Bag-valve Mask
2.
Advanced Airway (Consider Endotracheal Intubation)
3.
Mechanical Ventilations (Such As CPAP Or BIPAP)

When Providing Assisted Ventilations, Remember That
Hyperventilation (Ventilating Too Often, Too Rapidly, Or With Too
Much Volume) Will Diminish The Effectiveness Of Circulation.
Exhaled or End-Tidal CO2
Monitoring

When Available, Exhaled CO2 Detection (Capnography Or
Colorimetry) Is Recommended As Confirmation Of Tracheal Tube
Position For Neonates, Infants, And Children With A Perfusing Cardiac
Rhythm In All Settings

Remember That A Color Change Or The Presence Of A Capnography
Waveform Confirms Tube Position In The Airway But Does Not Rule Out
Right Mainstem Bronchus Intubation.

During Cardiac Arrest, If Exhaled Co2 Is Not Detected
1.
Confirm Tube Position With Direct Laryngoscopy
Absence Of Co2 May Reflect Very Low Pulmonary Blood Flow Rather
Than Tube Misplacement.
Exhaled or End-Tidal CO2
Monitoring

Confirmation Of Endotracheal Tube Position By Colorimetric End-tidal
CO2 Detector May Be Altered By The Following:
1.
If The Detector Is Contaminated With Gastric Contents Or Acidic Drugs
(Eg, Endotracheally Administered Epinephrine),
2.
A Consistent Color Rather Than A Breath-to-breath Color Change May
Be Seen
3.
An Intravenous (Iv) Bolus Of Epinephrine May Transiently Reduce
Pulmonary Blood Flow And Exhaled Co2 Below The Limits Of Detection
4.
Severe Airway Obstruction (Eg, Status Asthmaticus) And Pulmonary
Edema May Impair Co2 Elimination Below The Limits Of Detection
5.
A Large Glottic Air Leak May Reduce Exhaled Tidal Volume Through The
Tube And Dilute Co2 Concentration
Capnography Video
Oxygen

Ventilate with 100% oxygen during CPR because there is insufficient
information on the optimal inspired oxygen concentration once the
circulation is restored, monitor systemic oxygen saturation.

Titrate oxygen administration to maintain the oxyhemoglobin
saturation ≥94%-99%
6 H’s AND 5 T’s
T’s
H’s
1.
2.
3.
4.
Hypovolemia (Look For Signs Of
Fluid/Blood Loss. Give Fluid Blolus And
Reassess)
Hypoxia (Confirm Chest Rise And
Bilateral Breath Sounds With
Ventilation, Check O2 Source)
Hydrogen Ion Acidosis (Respiratory
Acidosis; Provide Adequate
Ventilation But Do Not
Hyperventilate, Metabolic Acidosis;
Give Sodium Bicarb)
Hyper/Hypokalemia (For Hyper Give
Calcium Chloride 10 Ml Of 10% Over 5
Minutes, For Hypo Give Potassium Or
Magnesium 5ml Of 50% Solution)
5.
Hyper/Hypothermia
6.
Hypo/Hyperglycemia (Check Glucose
With Accu-check)
1.
Tablets (Drug OD); Find Antidote Or
Reverse Drug, Poison Control. Always
Ask The Family For Metabolic Or Toxic
Causes During Resuscitation
2.
Tamponade (Look For Chest Trauma,
Malignancy, Central Line Insertion,
JVD)
3.
Tension Pneumothorax- Decreased
BS, Deviated Trachea, High Peak
Pressures Or Difficult To Bag, Chest
Tube With Needle Decompression
OVER THE THIRD RIB AT THE
MIDCLAVICULAR LINE
4.
Thrombosis- Give Thrombolytics For
Suspected Embolus
5.
Trauma- Inspect Body Completely,
Remove Clothing, Secure Airway,
Control Bleeding And Give Volume
With Isotonic Crystalloids And Blood
Products
Break Time 15 Min…
Arrhythmia
Review
Bradycardia

Bradycardia Occurs When The Heart Beats Slower Than 60 Beats
Per Minute. Occurs As A Result Of Heart Block Or Increased Vagal
Tone
What Do You Do
Support ABC As Necessary
1.
Give Oxygen
2.
Attach Monitor And Prepare Defibrillator
3.
Determine If Bradycardia Is Causing Cardiopulmonary
Compromise

If Causing Cardiopulmonary Compromise

Perform CPR If Despite Oxygenation And Ventilation With Bagging,
The Heart Rate Remains Below 60/Min With Poor Perfusion

If Bradycardia Persists When Rhythm Is Checked After 2 Minutes,
Give EPINEPHRINE And Repeat Every 3-5 Minutes As Necessary
Bradycardia

If Patient Has Increased Vagal Tone (Pathologic Causes Include
MI, Toxic/Environmental Exposure, Electrolyte Disorders,
Infection, Sleep Apnea, Drug Effects, Hypoglycemia,
Hypothryroidism, And Increased Intracranial Pressure)

Or Primary AV BLOCK
1.
Give ATROPINE First Dose 0.02 Mg/Kg, May Repeat (Minimum
Dose Is 0.1mg To Maximum Total Dose Of 1.0mg)
2.
Consider Pacing If Drugs Fail
3.
Watch For Asystole And Be Prepared To Perform CPR

If Bradycardia Is Not Causing Any Compromise
1.
Monitor Patient
2.
Supply Oxygen
3.
Acquire Expert Consultation
4.
Note Possible Causes H’s & T’s.
Transcutaneous Pacing

Not Commonly Performed With Pediatrics, However It Is Utilized To
Supplement A Failing Conduction System Associated With High
Degree Blocks Or Severe Unresponsive Bradycardia
ASYSTOLE

ASYSTOLE/Pulseless Arrest – Not Shockable (Course Guide, Page 39)

Remember The Acroynym DEAD

Determine Whether To Initiate Resuscitative Efforts.

Epinephrine 0.01 Mg/Kg (1:10,000 Solution) Q 3-5 Min IV/IO.
Give As Soon As Possible After Resuming CPR, Circulate
With Chest Compressions.

Aggressive Oxygenation – Use Compression/Ventilation Ratio
Of 15:2 Consider Advanced Airway. Avoid Hyperventilation

Differential Diagnosis Or Discontinue Resuscitation – Are They Still
Dead?

Consider The 6 H’s And 5 T’s (See Above)

Check Blood Glucose

Check Core Temp.

Consider Naloxone; Etc.
PULSELESS ELECTRICAL
ACTIVITY

Pulseless Arrest Is Not Shockable

Remember PEA

Possible Causes (Consider The 6 H’s And 5 T’s).

Epinephrine 0.01 Mg/Kg IV/IO Q 3-5 Minutes. Give As Soon As Possible
After Resuming CPR, Circulate With Chest Compressions.

Aggressive Oxygenation – Use Compression: Ventilation Ratio Of 15:2
Consider An Advanced Airway. Avoid Hyperventilation
PEA Will Have The
Appearance Of A Sinus
Rhythm, However No
Pulse Is Present
PULSELESS ELECTRICAL
ACTIVITY

In PEA, The Electrical System Of The Heart Is Functioning, But There Is A
Problem With The Pump, (Heart) Pipes, (Arterys/Veins) Or Volume
(Blood Amount)

A Mechanical Part Of The System Is Not Working. You Can Use The 6
H’s And 5 T’s To Remember The Most Common Reversible Causes Of
PEA
1.
Hypovolemia Toxins
2.
Hypoxia Tamponade, Cardiac
3.
Hydrogen Ion (Acidosis) Tension Pneumothorax
4.
Hypoglycemia Trauma
5.
Hypo-/Hyperkalemia Thrombosis (Coronary Or Pulmonary)
6.
Hypothermia
Pediatric Pulseless Arrest
Algorithm

BLS

Initiate CPR 30:2 Or 15:2 Ratios

Bag/Mask Ventilate With 100% Oxygen (Avoid
Hyperventilation)

Attach Monitor And Prepare Defibrillator

Check Rhythm Once On Monitor

Determine If The Rhythm Is Shockable (VT, VF)

Also A IV/IO Should Be Established And An Advanced
Airway Should Be Considered
Ventricular Tachycardia Without Pulse And
Ventricular Fibrillation
Pulseless V-Tach

VT- Series Of Wide Bizarre QRS That Produce Little To No Cardiac
Output; Rate Above 100
1.
Requires Immediate Defibrillation With 2J/Kg Followed By Immediate
CPR
2.
If After 2 Minutes Still In VT Or VF, Shock Again At 4J/Kg
3.
Establish IV And Give Epinephrine 0.01mg/Kg
Ventricular Tachycardia Without Pulse And
Ventricular Fibrillation
V-Fib

Chaotic; No Defined Rhythm, Never A HR/Pulse

Requires Immediate Defibrillation With 2J/Kg Followed By Immediate
CPR

If After 2 Minutes Still In VT Or VF, Shock Again At 4J/Kg

Establish IV And Give Epinephrine 0.01mg/Kg

Both Of These Arrhythmias Will Require Emergent CPR, Defibrillation
And Drugs
IF SHOCKABLE (VT, VF)
1.
Give 1 Shock (Manual Start With 2 J/Kg; AED Is Preset)
2.
Resume CPR Immediately After Shock
3.
Give 5 Cycles (Approximately 2 Minutes) And Then Check Rhythm Again
And Determine If Its Shockable

If It Is A Shockable Rhythum Continue CPR While Defibrillator Is Charging
And Administer Second Shock With 4 J/Kg
1.
Resume CPR
2.
Give Epinephrine

IV/IO 0.01 Mg/Kg Every 3-5 Minutes

ETT 1:10,000 Sol Every 3-5 Minutes

Keep Checking Rhythm After Every 2 Minutes To Determine If It Is Shockable

If After 3 Shocks VF Or VT Remain, Consider Antiarrythmics
1.
AMIODARONE 5 Mg/Kg IV/IO
2.
LIDOCAIN 1 Mg/Kg IV/IO
3.
Consider Magnesium 2.5-5 Mg/Kg IV/IO Max Dose 2g For Torsades

If Rhythm Continues The Same Consider H’s And T’s
End Of Day 1
Welcome Back (Day Two)
Resuscitation Team Concept
Tachycardia with Pulse and
Adequate Perfusion

Assess And Support ABC As Needed

Provide Oxygen, Do Not Rely On Spo2 Monitor, May Be Unreliable
(Nasal Cannula, Mask, Non Rebreather)

Attach Monitor, Prepare Defibrillator

Evaluate/Obtain A 12 Lead EKG

On EKG If QRS Is Normal (0.08 To 0.12 Seconds)

Probable Sinus Tachycardia

Compatible With History Consistent With Known Cause (Fever,
Fear, Pain, Anxiety)

P Waves Present/Normal

Variable R-R With Consistent PR

Infants: Rate Usually <220/Min; Children Rate Usually <180/Min

Treat Causes (This Will Return Rate To Normal)
Tachycardia With Pulse And
Adequate Perfusion

On EKG If QRS Is Narrow (Less Than 0.08 Seconds)

Probable Supraventricular Tachycardia (SVT)

Compatible History (Vague, Non Specific, Abrupt Rate Changes)

P Waves Absent/Abnormal

HR Not Variable With Activity

Infants Rate >220/Min, Children Rate > 180/Min

Treatment
1.
Consider Vagal Maneuvers First If Stable (Ideal Vagal Is Ice To Face In Infants)
2.
Establish IV And Consider ADENSOSINE 0.1 Mg/Kg IV
(Maximum First Dose 6 Mg). Use Rapid Bolus Technique W/20 cc NS Flush
3.
If Patient Is Unstable And Has No IV, Cardiovert Immediately
Tachycardia With Pulse And
Adequate Perfusion

On EKG If QRS Is Wide (Greater Than 0.12 Seconds)

Possible Ventricular Tachycardia

Search And Treat Possible Causes, Consider Expert Consultation

Consider Pharmacologic Cardioversion
1.
Amiodarone 5 Mg/Kg IV Over 20-60 Minutes
2.
Procainamide 15 Mg/Kg Over 30-60 Minutes

(Both Will Slow Ventricular Conduction And Improve Contractility,
Thus Increasing Cardiac Output)

Do Not Administer Amiodarone And Procainamide Together

May Attempt Adenosine If Not Already Administered

Consider Electrical Cardioversion For Unstable Patients Or If Medications Fail

Sedate Prior To Cardioversion

Cardiovert With 0.5 To 1 J/Kg (May Increase To 2 J/Kg If Initial Dose Is Ineffective)

Obtain 12 Lead EKG
Pediatric Tachycardia With
Pulses With Poor Perfusion

Same As Previous Slide

DO NOT DELAY CARDIOVERSION FOR IV Access And Consider Possible
Causes H’s And T’s
Cardioversion Verse
Defribillation

Cardioversion-With Sync Mode On 0.5 To 1 J/Kg

For Unstable SVT, VT, A-fib, A-flutter Not Controlled By Adenosine Or
Vagal Manuvers

May Increase To 2 J/Kg If 1st Shock Is Unsuccessful

Use Sedation With Analgesia When Possible

Cardiovert If Vascular Access Is Not Established

Do Not Delay Cardioversion To Establish IV/IO

Defibrillation-Unsynchronized 2-4 J/Kg
1.
Increase Joules For VT/VF
2.
Perform Immediate CPR After Shock
3.
Assess Rhythm Every 2 Minutes
4.
Epinephrine Should Be Given 3-5 Minutes 0.01 Mg/Kg
Split up into two groups

Group 1:

Pulseless Arrest Algorithm

Drug Management

VF/VT Algorithm

Bradycardia Algorithm

Tachycardia Algorithm

Group 2:

Review Defibrillation


Cardioversion
Transcutaneous Pacing
Break Time
Broselow Tape
Vascular Access
Medications And
Administration

Preferred Route IV/IO Because ETT Route Is Unreliable In Dosing And
Absorption

Prolonged Use Of Epinephrine With Increasing Does No Longer Done
https://www.youtube.com/watch?v=0roDPk-VpAo
Medications
Adenosine

0.1 mg/kg (Up To 6 mg)

0.2 mg/kg For Second Dose

Rapid IV Push Followed By 20cc N/S Flush, Max Single Dose 12 mg.

For SVT (After No Response By Vagal Maneuvers)
Amiodarone

5 mg/kg Rapid IV/IO

Max 15 mg/kg/Day For Refractory Pulseless VT/VF
Atropine

0.02 mg/kg IV/IO

Min Dose 0.1 mg

Max Single Dose 0.5 mg

1 mg Adolescent, May Double Second Dose.

For Bradycardia After Epinephrine
Medications
Dobutamine
 2-20 ug/kg/min
 Titrate To Desired Effect
Dopamine
 2-20 ug/kg/min
 Presser Effects At Higher Doses>15 ug/kg/min
Epinephrine
 0.01 mg/kg (1:10,000) IV/IO
 0.1 mg/kg (1:1000) ETT
 Repeat Every 3-5 Minutes During CPR
 Consider A Higher Dose (0.1mg/kg) For Special Conditions
 Given for VT/VF, Asystole, PEA, Bradycardia
Glucose
 0.5-1 g/kg IV/IO Max Dose 2-4 mL/kg of 25% Solution
 5%= 10-20 mL/kg, 10%= 5-10 mL/kg, 25%= 2-4 ml/kg In Large Vein
Medications
Lidocain

1 mg/kg

IV/IO/TT (With TT Dilute With NS To A Volume Of 3-5 Ml And Follow With
Positive Pressure Ventilations. Given As A Alternative To Amiodarone
Magnesium Sulfate

25-50 mg/kg IV/IO Over 10-20 min

Max Dose 2g, Given For Torsades De Pointes
Naloxone

If <5 yr old or 20 kg: 0.1 mg/kg

If >5 yr old or 20 kg, 2 mg

Titrate To Desired Effect, For Barbituate Overdose
Sodium Bicarb

1 mEq/kg Per Dose

Infuse Slowly And Only If Ventilation Is Adequate
Management of Shock
1.
Give Oxygen
2.
Monitor Pulse Ox
3.
ECG Monitor
4.
Blood Pressure
5.
IV/IO Access
6.
BLS As Indicated
7.
Bedside Glucose
Management Of Shock

Shock Results From Inadequate Blood Flow And Oxygen Delivery To
Meet Tissue Metabolic Demands

Shock Progresses Over A Continuum Of Severity, From A
Compensated To A Decompensated State

Attempts To Compensate Include Tachycardia And Increased
Systemic Vascular Resistance (Vasoconstriction) In An Effort To
Maintain Cardiac Output And Blood Pressure

Although Decompensation Can Occur Rapidly, It Is Usually Preceded
By A Period Of Inadequate End-organ Perfusion
Sings Of Shock Include
1.
Tachycardia
2.
Cool extremities
3.
Prolonged capillary refill (despite warm ambient temperature)
4.
Weak peripheral pulses compared with central pulses
5.
Normal blood pressure

As compensatory mechanisms fail, signs of inadequate end-organ
perfusion develop. In addition to the above, these signs include
1.
Depressed mental status
2.
Decreased urine output
3.
Metabolic acidosis
4.
Tachypnea
5.
Weak central pulses
Management Of Shock

Signs Of Decompensated Shock Include The Signs Listed Above Plus
Hypotensio

In The Absence Of Blood Pressure Measurement, Decompensated
Shock Is Indicated By The Nondetectable Distal Pulses With Weak
Central Pulses In An Infant Or Child With Other Signs And Symptoms
Consistent With Inadequate Tissue Oxygen Delivery

The Most Common Cause Of Shock Is Hypovolemia

One Form Of Which Is Hemorrhagic Shock

Distributive And Cardiogenic Shock Are Seen Less Often

Learn To Integrate The Signs Of Shock Because No Single Sign
Confirms The Diagnosis
Example Of Shock

Capillary Refill Time Alone Is Not A Good Indicator Of Circulatory
Volume, But A Capillary Refill Time Of >2 Seconds Is A Useful Indicator
Of Moderate Dehydration When Combined With
1.
Decreased Urine Output
2.
Absent Tears
3.
Dry Mucous Membranes
4.
Generally Ill Appearance

It Is Influenced By Ambient Temperature, Lighting, Site, And Age

Tachycardia Also Results From Other Causes

Pain

Anxiety

Fever
Management of Shock

Pulses May Be Bounding In

Anaphylactic

Neurogenic

Septic Shock.

In Compensated Shock, Blood Pressure Remains Normal

It Is Low In Decompensated Shock

Hypotension Is A Systolic Blood Pressure Less Than The 5th Percentile
Of Normal For Age, Namely

● <60 mm Hg In Term Neonates (0 To 28 Days)

● <70 mm Hg In Infants (1 Month To 12 Months)

● <70 mm Hg + (2 X Age In Years) In Children 1 To 10 Years

● <90 mm Hg In Children >10 Years Of Age
Practice Time

Six Year Old Min. Systolic Blood Pressure

6 * 2 + 70 = 82
1.
Two Year Old Min. Systolic Blood Pressure
2.
Five Year Old Min. Systolic Blood Pressure
3.
Nine Year Old Min. Systolic Blood Pressure
4.
Twelve Year Old Min. Systolic Blood Pressure
Management Of Shock
Hypovolemic Shock
1.
Signs And Symptoms Of Shock
2.
Pale/Cool/Clammy Skin
3.
4.
5.

Increased HR
BP Is Low (Decompensated) Or Normal (Compensated)
Obtunded
Non-hemorrhagic
1.
20 ml/kg NS Or LR Bolus, Repeat As Needed
2.
Consider Colloid After 3rd NS/LR Bolus

Hemorrhagic
1.
Control Bleeding
2.
20 ml/kg NS/LR Bolus
3.
Repeat 2 Or 3 Times As Needed/Transfuse PRBC As Indicated
Management Of Shock

Causes Of Hypovolemic Shock In PALS
1.
Dehydration from illness
2.
Trauma from accidents
3.
Diarrhea, vomiting

Septic Shock

Common With Sustained Infection, Chronic Disease, Immune
Compromised And Cancer Patients On Chemotherapy

Altered Mental Status And Perfusion
1.
Give O2 And Support Ventilation As Needed
2.
Establish IV/IO
3.
Obtain ABG, Lactate, Glucose, Calcium, Cultures And CBC
4.
BLS As Needed
Management of Shock

Push 20 Ml/Kg Boluses Of Isotonic Fluid Up To 3, 4 Or More Blouses Based On
Patient Response

Correct Hypoglycemia And Hypokalemia As Needed

Administer Antibiotics STAT

Consider Vasopressor Drip To Maintain BP And Stress Dose Hydrocortisonse
(Used To Treat Shock)

If Patient Responds To Fluid With Normal BP Send To ICU To Monitor

If Patient Does Not Respond: Begin Vasoactive Drugs;

Establish A-line For BP Monitoring

Central Line For Fluid Delivery

Administer Dopamine For Renal Perfusion

Administer Norepinephrine (Levophed) For Blood Pressure

Evaluate SVO2 (Goal Greater Than 70%, Obtained From PA Line)

If SVO2 Is Less Than 70% Consider MILRINONE Or NITROPRUSSIDE
Management Of Shock
Neurogenic Shock (Head Injury That Disrupts BP Regulation)

Give 20 Ml/Kg NS/LR Bolus Repeat PRN

Give Vasopressor
Cardiogenic Shock

Follow PALS Algorithms For Bradycardia And Tachycardia

Other Such As Cardiomyopathy, Myocarditis, CHD Or Poisoning Give 5-10 ml/kg
NS/LR Bolus, Repeat PRN

Give Vasoactive Infusion And Consider Expert Consultation
Obstructive Shock

1.

1.

1.

1.
Tension Pneumothorax
Needle Decompression And Chest Tube
Ductal Dependent
Prostaglandin, And Cardiologist Consultation
Cardiac Tamponade
Pericardiocentesis And 20 Ml/Kg Bolus NS
Pulmonary Embolism
20 Ml/Kg Bolus, Thrombolytics And Anticoagulants
Lunch Time 45 Min…
Overview Of Pediatric
Assessment
Pediatric Assessment

The AHA Utilizes A Specific Assessment Protocol Known As

Assess – Categorize –Decide – Act -- Model
1.
Assess The Patient
2.
Categorize The Nature And Severity Of Their Illness
3.
Decide On The Appropriate Actions
4.
Act Appropriately

Once You Have Completed This Process, Begin Again By Reassessing
The Patient

Always Seeking Additional Information That Will Help In Determining
The Nature Of The Illness Or Treatment Of The Patient.
Pediatric Assessment
Assess

Categorize Illness As A Respiratory, Circulatory Or A Combination
Problem Assess Severity Of Problem
Respiratory

Upper Vs. Lower Airway Obstruction

Lung Tissue Disease

Disordered Control Of Breathing (Head Injury)

Severity: Respiratory Distress, Impending Or Failure
Pediatric Assessment
Circulatory (Arrhythmia Or Shock)

SHOCK: Give Repeated Boluses Of Isotonic Crystalloid (NS Or LR) Of
20 Ml/Kg For HYPOTENSION Associated With Shock

Isotonic Colloid Given Only After Crytalloid Is Give
1.
Hypovolemic: Loss Of Blood, Dehydration, Vomiting, Diarrhea
2.
Obstructive: Neurological Impairment Affecting Skeletal Muscles
3.
Distributive/Septic: Infection Migrating To Major Organs
4.
Cardiogenic: Multiple Areas Of Ischemic Damage To The Heart
Leading To Poor Output.

Give Vasoactive Drugs Such As Milrinone For Compensated Shock.

Give Medium Does Of Dopamine For Uncompensated Shock With
Boluses Of Fluid

Avoid Epinephrine As It Increases Myocardium O2 Demand Making
Ischemia Worse
Pediatric Assessment

Severity

Compensated (Normotensive, Normal Systolic BP But Will Have A
Decreased Level Of Consciousness, Cool Extremities, Delayed
Capillary Refill And Faint Distal Pulses)

Uncompensated (Results In Increased HR, Low BP, And Weak Pulses)

General Assessment

Inspection (WOB, Appearance, Color, Edema, Alertness…)

Primary Assessment

Circulation, Airway, Breathing, Disability, Exposure

Vitals, Spo2, Neuro Status (Such As A Patient Whom Responds To
Painful Stimulus By Grabbing Your Hand If Pinched But Otherwise Does
Not Respond Verbally) Temperature And Bleeding
Pediatric Assessment

Secondary Assessment

Focus On History (SAMPLE)
1.
Signs And Symptoms
2.
Allergies
3.
Medications
4.
Past Hx
5.
Last Meal Consumed
6.
Events Leading To Present Problem

This Is A Thorough Head To Toe Examination Tertiary Assessment

Lab Studies, Cxr, Ekg, Abg…know When To Obtain Each.

Ex--Know When To Obtain A Head CT For A MVA Patient Whom
Is Unresponsive With No Signs Of Pneumothorax
Pediatric Assessment

As You Provide Treatment, You Must Frequently Reassess Your Patient
(Especially After Initiating A Therapy Or Intervention)

Then Re-categorize The Patient Based On The Information Available
To You

What You First Categorize (Correctly) As Respiratory Distress May Turn
Out To Be The Result Of A Life-threatening Dysrhythmia

You Would Need To Recategorize The Problem As Cardiac Once You
Identify The Heart Rhythm

Then Treat The Patient Appropriately.
Pediatric Assessment
Pediatric Assessment

Cardiac

Common Life-threatening Dysrhythmias Include
1.
Supraventricular Tachycardia
2.
Bradycardia (In Pediatric Patients Severely Symptomatic
Bradycardia May Require CPR)

Patients In Cardiac Arrest May Be In
1.
Ventricular Fibrillation
2.
Pulseless Ventricular Tachycardia
3.
Asystole
4.
Pulseless Electrical Activity (PEA)

Which Includes All Other Heart Rhythms That Present Without A
Pulse
Pediatric Assessment

Respiratory

Respiratory Problems Can Be Broadly Divided Into

Upper Airway Obstruction

Lower Airway Obstruction

Lung Tissue Disease

Disordered Control Of Breathing

(Which Includes Any Ineffective Respiratory Rate, Effort, Or Pattern
Pediatric Assessment

Shock

Shock (Widespread Inadequate Tissue Perfusion) Can Be

Hypovolemic

Obstructive

Distributive (Septic)

Cardiogenic

If A Patient’s General Appearance Indicates That They May Be
Unconscious, You Should Check For Responsiveness.

If The Patient Is Unresponsive, Get Help (Send Someone To Call 911
And Bring Back An AED, Call A Code, Etc.)
Pediatric Assessment

Remember Your BLS Algorithm Should Then Be Followed

Open The Airway

Check For Breathing

Assess Circulation

If The Patient Is Apneic, Start Rescue Breathing

If The Patient Is Pulseless (Or If A Pediatric Patient Has A HR Less Than
60 With Serious Signs And Symptoms), Rescuers Should Begin CPR.
Break Time 15 Min…
Core Case Simulations
Test Review

Respiratory Distress Is Defined As An Increase WOB, Tachypnea With
Or Without Desaturation

Respiratory Failure Is Inadequate Oxygenation/Ventilation

Lower Airway Problems Are Wheezing, Prolonged Expiratory Times

Upper Airway Problems Are Inspiratory Stridor

Disordered Control Of Breathing Are Erratic Breathing Patterns

Administer 20 Ml/Kg Of Isotonic Crystalloid Over 5-10 Minutes Initially
For All Shocks Except Cardiogenic (10 Ml/Kg)

IO Lines Are Ideal For Shock Patients, They Are Easy To Insert And Are
Quickly Done, Unlike Peripheral Access

Obtain A Bedside Glucose After Fluid Administration For Patients In
Shock

Needle Decompression Location For Pneumos

Know Compensated Vs. Hypotensive Shock
Test Review

Know BP Ranges For Age Groups

For SVT, If Unstable Then Cardioversion 0.5-1 J/kg.

If Stable Vagals First, (Ice To Face) Then Adenosine, Then Shock

Spo2 Range For Children Post ROSC= 94-99%

Suctioning May Cause Bradycardia Due To Vagal Stimulation, Be
Prepared To Intervene If HR Does Not Return To Normal

Remember DOPE For Distress After Intubation

Give IM Epi For Anaphylactic/Allergic Reactions

First Drug Of Choice For Pulseless Arrest, PEA, VF/VT, Bradycardia
Is Epi 0.01 Mg/Kg

Defibrillate VF/VT Without Pulse, First At 2 J/Kg Then 4 J/Kg
Test Review

CPR And The Process CAB

10 Seconds Or Less Palpating A Pulse

Ratio 30:2 Or 15:2 With 2 Rescuers

1/3 A/P Diameter

Check Pulses In Infants And Small Children In The Brachial Artery

Use An AED On All Patients If Warranted.

If Pediatric Size Pads Are Not Available For An Infant You May Use
Adult Pads (Anything Is Better Than Nothing)

Attach AED As Soon As It Arrives In A Code

Most Pediatrics Have Respiratory Failure Than Leads To Cardiac

If A Patients Breathing Slows, Their HR Will Follow


Bag The Patient To Increase The HR
Know All Algorithms
Testing and Megacode

Mega code and Testing

Groups of 5 for the mega code

You will rotate through and then return to the exam