Pediatric Cardiopulmonary Resuscitation
Suzan Schneeweiss
Introduction
Pediatric cardiac arrest is usually caused by an underlying respiratory abnormality
In general, the myocardium in children is normal, and the final common pathway leading to cardiac arrest is usually hypoxia
Second most common cause of cardiac arrest is circulatory failure from hypovolemia (loss of fluid or blood) or sepsis
Airway
Open the Airway
Similar maneuvers may be used in children and adults
Characteristics of childhood airway:
Large tongue proportional to the oral cavity
Higher and more anterior larynx (C3-4) vs (C5-6)
Long, floppy epiglottis
Subglottic area is narrowest portion of the infant larynx
Large head: when lying supine on backboard, neck is relatively flexed due to the large occiput and may obstruct the airway; if there is no evidence of trauma a towel placed under the head and shoulders will help position the airway
Tracheal Intubation
Best method for establishing and maintaining a patent airway in children who are comatose or in those with respiratory or cardiac arrest
Rapid sequence intubation to facilitate intubation and reduce complications
Sedative, neuromuscular blocking agent and other medications to sedate and paralyze patient
Requires skilled personnel
Verification of tube placement: clinical assessment and confirmatory devices
End-tidal CO2 monitor; positive waveform or color change
Consider esophageal dectector device in children > 20 kg with a perfusing rhythm
Bilateral chest movement; equal breath sounds over both lung fields
Listen for gastric insufflation sound over stomach
Check oxygen saturation
If uncertain, perform direct laryngoscopy
Chest X-ray: confirm placement (not in right mainstem bronchus or high position)
If deterioration of patient condition, consider DOPE:
Displacement of tube from trachea
Obstruction of endotracheal tube
Pneumothorax
Equipment failure
Estimation of Size of ETT in Children
Child > 1 yr = (age/4) + 4 (uncuffed tube)
Internal diameter of ETT = size of child’s little finger (less reliable)
Length-based resuscitation tapes (Broselow® tape)
Consider cuffed endotracheal tube in hospital setting
Laryngeal Mask Airway (LMA)
If endotracheal tube placement is not possible, LMA acceptable adjunct for experienced providers
Contraindicated if intact gag reflex
Does not protect airway from aspiration
More difficult to maintain during patient movement than ETT
Should not replace BVM ventilation
LMA sizes:
•
Neonates
1-1.5
•
7.5-10 kg
1.5
•
10-20 kg
2
•
20-30 kg
2.5
•
30-50 kg
3
•
> 50 kg
3-4
Breathing
Impending Respiratory Failure
Increased respiratory rate and effort or decreased breath sounds
Increased work of breathing
Nasal flaring, use of accessory muscles
Head bobbing, grunting
Stridor and/or prolonged expiration
Decreased level of consciousness or response to pain or stimulation
Poor skeletal muscle control
Slow or irregular respirations (ominous sign of impending arrest)
Cyanosis
Note: Tachypnea without other signs of respiratory distress quiet tachypnea is often an attempt at maintaining normal pH (compensatory respiratory alkalosis) in response to metabolic acidosis
Bag-Valve-Mask (BVM) Ventilation
As effective as ventilation through endotracheal tube for short periods
Caution against overventilation
Reduced cardiac output, cerebral blood flow, and coronary perfusion
Air-trapping and barotrauma: increased risk of stomach inflation, regurgitation, and aspiration
Two-person technique more effective than one-person technique
One person maintains open airway with jaw thrust and tight mask-to-face seal while other person compresses ventilation bag
Self-Inflating BVM Device
Mask should fit over mouth and nose to provide a tight seal and avoid air leakRelated posts:
Full access? Get Clinical Tree
