Transcript Basic life support in infants and children

PEDIATRICS
Pediatric Basic Life Support
Toktam Faghihi, Pharm.D
TUMS
EPIDEMIOLOGY
Cause of Cardiopulmonary arrest:
Adults: most common cause of cardiac arrest:
ischemic cardiovascular disease: a primary
cardiac event
Infants and children is a terminal result of
respiratory failure and/or shock: progressive
tissue hypoxia and acidosis
EPIDEMIOLOGY…
• Adult cardiac arrest: focused on diagnosis and
treatment of ventricular fibrillation (VF).
• Studies showed that VF was the most common
initial dysrrhythmia in adults with sudden death, in
some reports the prevalence of VF was 60% to
85%.
• Cardiac arrest due to VF as the initial cardiac
rhythm occurs in only 5% to 15% of pediatrics.
EPIDEMIOLOGY…
• Children: arrest is the terminal result of
progressive respiratory failure or shock.
• It is essential to recognize and treat pediatric
patients with respiratory distress, pneumonia
and shock to prevent the development of
systemic hypoxemia, hypercapnia, acidosis that
may then progress to bradycardia, hypotension
and eventually cardiorespiratory arrest.
EPIDEMIOLOGY…
• Causes of respiratory failure and shock:
accidents, sudden infant death syndrome
(SIDS), respiratory distress, and sepsis.
• Respiratory distress:
Respiratory Distress
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Respiratory rate and effort
Work of breathing
Quality and magnitude of breath sounds
Patients mental status
Respiratory Rate
• Tachypnea is one of the most important
findings in children with respiratory disease.
Age
RR (breaths/min)
Tachypnea (breaths/min)
Newborn- 2 months
30-60
>60
2 months-12 months
25-40
>50
1-3 years
20-30
>40
3-6 years
16-22
>40
7-12 years
14-20
>40
> 12 years
12-20
>40
Intercostal, subcostal and supracostal
retractions increase with increasing
respiratory distress.
• Nasal flaring: an effort to
increase airway diameter,
and is often seen with
hypoxemia
Sudden infant death syndrome
(SIDS)
• The sudden death of an infant less than one
year of age, which remains unexplained after a
thorough case investigation.
• The mechanism of sudden death is unknown.
• The most compelling hypothesis involves a
brainstem abnormality or maturational delay related
to neuroregulation or cardiorespiratory control,
combined with a trigger event such as airflow
obstruction.
SIDS…
• Number of risk factors for SIDS have been identified:
Exposure to cigarette smoke
Low birth weight,
prematurity,
Prone sleep position - 1.3-fold increased risk,
soft bedding,
soft sleep surfaces,
bed-sharing,
Overheating (excessive clothing).
 Breast feeding
Apparent Life-Threatening Event (ALTE)
• Not a specific diagnosis but a description of an acute,
unexpected change in an infant's breathing behavior
that is frightening to the caretaker and that includes some
combination of the following features:
• Apnea — usually no respiratory effort (central) or
sometimes effort with difficulty (obstructive)
• Color change — usually cyanotic or pallid but
occasionally erythematous or plethoric
• Marked change in muscle tone (usually limpness or rarely
rigidity)
• Choking or gagging
ETIOLOGY
• specific cause for the ALTE can be identified in
over one-half of patients after a careful history,
physical examination, and appropriate laboratory
evaluation:
• Gastroesophageal reflux
• Neurologic problems (such as seizures or
breath-holding spells)
• Infection
ALTE
Acute conditions
Chronic conditions
Infections
Gastrointestinal
Respiratory infections (eg, pertussis,
respiratory syncytial virus, bronchiolitis)
Gastroesophageal reflux
Sepsis, meningitis, encephalitis
Swallowing incoordination
Gastrointestinal
Neurologic
Intussusception, Volvulus
Seizure
Drug effect
Vasovagal syncope
Cold medications
CNS hemorrhage
• October 2010, the American Heart Association
(AHA)
• and Heart and Stroke Foundation of Canada
(HSFC)
• updated Guidelines on Pediatric Basic Life
Support (PBLS)
• and Pediatric Advanced Life Support (PALS).
Pediatric Basic Life Support (PBLS)
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Introduction
Basic Life Support Sequence
Ventilation
Chest Compressions
Introduction
• Basic life support (BLS) involves a systematic
approach to initial patient assessment, activation of
emergency medical services, and the initiation of
cardiopulmonary resuscitation (CPR), including
defibrillation.
• Key components of effective CPR include:
adequate ventilation
and
chest compressions
Introduction…
• For the purposes of these guidelines:
• a newborn is defined as from birth to hospital
discharge
• an infant is younger than one year of age,
• a child is from one year to the start of puberty.
Normal Vital Signs According To Age
Age
HR (beats/min)
BP (mmHg)
RR (breaths/min)
Premature
120-170
55-75/35-45
40-70
0-3 mo
100-150
65-85/45-55
35-55
3-6 mo
90-120
70-90/50-65
30-45
6-12 mo
80-120
80-100/55-65
25-40
1-3 yr
70-110
90-105/55-70
20-30
3-6 yr
65-110
95-110/60-75
20-25
6-12 yr
60-95
100-120/60-75
14-22
12+ yr
55-85
110-135/65-85
12-18
Pediatric Basic Life Support (PBLS)
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Introduction
Basic Life Support Sequence
Ventilation
Chest Compressions
BASIC LIFE SUPPORT SEQUENCE
• Activate EMS
• Initiate CPR — The actions that constitute
cardiopulmonary resuscitation (CPR) are
opening the airway, providing ventilations
(rescue breaths), and performing chest
compression.
BASIC LIFE SUPPORT SEQUENCE…
• The sequence in which the actions of CPR for
infants and children should be performed by health
care providers is as follows:
Initiate CPR in an infant or child who is
unresponsive and not breathing (or only gasping).
If there is no pulse or it is not definitively identified
within 10 seconds, then start compressions
BEFORE performing airway or breathing
maneuvers.
BASIC LIFE SUPPORT SEQUENCE…
After 30 compressions (15 compressions if two rescuers) open
the airway and give two breaths.
If a definite pulse is found within 10 seconds, provide
ventilation only
If the pulse is ≥60 beats per minute (bpm), continue
ventilation
If the pulse is <60 bpm, add chest compressions to
ventilation
ABC vs CAB?
• The Change of Sequence from ABC to CAB
• “A-B-C” i.e. Airway, Breathing, and Chest
Compression to “C-A-B” i.e. Chest
Compressions first
Rationale 1
• Reluctance to initiate CPR may, in part, relate
to the technical difficulty in opening the
airway and delivering rescue breaths.
• Therefore, starting with chest compressions
(the ‘simpler’ component of CPR) may
encourage more witnesses to act when faced
with victims of cardiac arrest.
Rationale 2
• The majority of cardiac arrest victims are
adults where Ventricular Fibrillation (VF) or
pulseless Ventricular Tachycardia (VT) is
common.
• Those victims have better survival when the
arrest is witnessed and when chest
compression and defibrillation are initiated
rapidly.
Rationale 3
• In contrast to adults, cardiac arrests in infants
and children are usually asphyxial in nature
i.e. secondary to hypoxia or shock (which, if
left untreated, leads to progressive
bradycardia and ultimately asystole, not
primary VF as in adults).
• Thus ventilation is critically important in
pediatric resuscitation.
Rationale 3…
• However, performing 30 chest compressions before
ventilation will theoretically only delay ventilation by
approximately 18 seconds (for the lone rescuer) and even
less for two healthcare providers.
• This minimal delay is unlikely to affect the outcome of
resuscitation, but will probably generate blood flow to vital
organs sooner.
• There is no evidence to suggest that starting with
ventilation (as in ABC) is superior to starting with chest
compressions (as in CAB).
• High quality CPR focuses on:
• Effective delivery of chest compressions
• And avoidance of excessive ventilation
Pediatric Basic Life Support (PBLS)
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Introduction
Basic Life Support Sequence
Ventilation
Chest Compressions
Ventilation
• hyperventilation is associated with increased
intrathoracic pressure and decreased coronary
and cerebral perfusion.
Ventilation…
Recommendations:
• Each rescue breath should be delivered over one second.
• The volume of each breath should be sufficient to see the chest
wall rise.
A child with a pulse ≥60 bpm who is not breathing should receive
one breath every three to five seconds (12 to 20 breaths per
minute).
Infants and children who require chest compressions should receive
two breaths per 30 chest compressions for a lone rescuer and two
breaths per 15 chest compressions for two rescuers.
Intubated infants and children should be ventilated at a rate of 8 to
10 breaths per minute without any interruption of chest
compressions.
Pediatric Basic Life Support (PBLS)
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Introduction
Basic Life Support Sequence
Ventilation
Chest Compressions
Chest Compressions
• The 2010 international resuscitation guidelines
emphasize the importance of hard, fast chest
compression, with full chest recoil and minimal
interruptions.
Chest Compressions…
• Chest compressions should be performed over the lower half
of the sternum.
• Compression of the xiphoid process can cause trauma to the
liver, spleen, or stomach, and must be avoided.
• The chest should be depressed at least one-third of its
anterior-posterior diameter with each compression
(approximately 4 cm [1 ½ inches] in most infants and 5 cm [2
inches] in most children).
• The optimum rate of compressions is approximately 100 per
minute.
• Each compression and decompression phase should be of
equal duration.
• The sternum should return briefly to its normal position at the
end of each compression, allowing the chest to recoil fully.
COMPRESSION TO
VENTILATION RATIO
• every effort should be made to avoid excessive ventilation
and to limit interruptions of chest compressions to less
than ten seconds.
• For lone rescuers, two ventilations should be delivered
during a short pause at the end of every 30th
compression.
• For two rescuers, two ventilations should be delivered at
the end of every 15th compression.
• Once the trachea is intubated, ventilation and
compression can be performed independently.
• Ventilations are given at a rate of 8 to 10 per
minute.
• Compressions are delivered at a rate of 100 per
minute without pauses.
Conventional vs compression-only CPR???
• Although compression-only CPR (CO-CPR) is
suggested in limited situations in adults with
cardiac arrest.
• Conventional CPR is recommended in infants
and children, because cardiac arrest in this
population is more commonly due to hypoxia
when compared to adults.
In Summary
Key elements of high quality CPR:
• Push fast (at least 100/min)
• Push hard (4 cm in infant, 5 cm or 1/3 of chest depth in
• children)
• Allow full chest recoil between compressions
• Avoid excessive ventilation
• Minimize interruptions
• Resume CPR immediately after a shock
• Rotate compressor role every 2 min (to avoid fatigue).
Thank You
Questions?