Paed ALS

Question 1

Primary causes of cardiac arrest

Answer 1

-less common in children
-sudden/ unpredictable
-often due to arrythmia
-hypoxia and acidosis not initially present
-outcome depends on early defib

Question 2

Secondary causes of cardiac arrest

Answer 2

-most common in children
-heart stops due to ischaemia or hypoxia secondary to another condition
-arrest rhythm most likely bradycardia progressing to asystole
-hypoxia initially present

Question 3

Cardiac arrest pathways

Answer 3

Resp distress -> resp failure -> resp arrest -> cardiac arrest
Tachypnoea-> bradypnoea-> apnoea-> cardiac arrest
Raised BP-> falling BP-> cardiac arrest
Tachycardia-> bradycardia-> cardiac arrest

Question 4

Age definitions

Answer 4

Neonate- within 4 wks of birth
Infant- under 1
Child- between 1yr and puberty (SWAST) however RCUK, JRCALC, child= 1-18

Question 5

Paed arrest algorithm

Answer 5

-SCENE assessment (request HEMS)
-PAT- focus on breathing
-Cat haem
-Airway- head tilt chin lift (method on next slide)
-Check for breathing and pulse (separate flashcard)
-5 initial rescue breaths
-no signs of life after rescue breaths?
-start compressions and attach pads

Question 6

Manual airway management in paeds

Answer 6

Infant- blanket under the shoulders due to having a large head
Small child (1-5/6/7)- just flat on floor, nothing under head or shoulders
Older child/adult- blanket under head

Question 7

Check for breathing and pulse

Answer 7

-Open airway with head tilt chin lift and look for signs of life
Pulse
U1- feel brachial
Over 1- carotid

Question 8

5 initial rescue breaths

Answer 8

-insert OPA with tongue depressor
-use appropriately sized BVM
-5 rescue breaths with 2 person technique
During breaths look for:
-changes to skin colour (perfusion)
-movement or change in muscle tone
-if any of these signs check for spontaneous breathing/ pulse
-if no signs of life start compressions

Question 9

Attaching pads

Answer 9

-put zoll into paed mode by attaching paed pads or pressing paed mode on zoll screen
-paed pads- 28days- 8yrs old
-adult pads- 8yrs+
-AP pad placement in children up to 25kg or if unable to achieve 2cm gap (page for age estimates under 8yrs old= under 25kg)
(IN KIDS MAINLY DO AP)
-shock given at 4j/kg however this is worked out automatically by monitor

Question 10

Compressions

Answer 10

15:2
-various techniques depending on age
-4cm depth in infants, 5cm depth in children/ 1/3 depth of chest
-if pulse under 60 OR unsure of presence of pulse it still counts as cardiac arrest so begin compressions
-use compression technique that allows you to get adequate depth whilst not causing damage
-adult or large child use 2 hands
-child- 1 hand
-2 finger technique for infants has been changed since recent guidelines- DONT DO IT
-instead for infants use 2 handed encircling technique

Question 11

Shockable rhythm algorithm

Answer 11

-Confirm arrest, pads, analyse rhythm, VF or pVT, give shock
-upgrade to igel
-Rhythm check- VF or pVT, shock
-continue CPR and ventilate
-once backup arrived get IO access (HEMS?)
-after 3rd shock, give adrenaline and amiodarone
-once ALS established consider reversible causes, resus line?, consider early conveyance
-after 5th shock give adrenaline and amiodarone (NO HALF DOSE FOR PAEDS)
-if get to 6th shock increase energy to 8j/kg before giving 6th shock (max 360j) (however should be done automatically by monitor)
-continue giving adrenaline every 3-5minutes

Question 12

Non shockable algorithm

Answer 12

-Confirm arrest, pads, analyse rhythm, asystole or PEA
-upgrade to igel
-Rhythm check- asystole or PEA
-continue CPR and ventilate
-once backup arrived get IO access (HEMS?)
-give adrenaline ASAP
-once ALS established consider reversible causes, resus line?, consider early conveyance
-continue giving adrenaline every 3-5mins

Question 13

Airway management in arrest

Answer 13

-OPA for rescue breaths with BVM, ensure 2 person technique
-upgrade to igel asap
-consider not using catheter mount if pt is under 1 as it would reduce the dead space
-DON’T LET GO OF BVM
-IF DEFIBRILLATING DETACH BVM FROM AIRWAY TREE

Question 14

Ventilations during arrest

Answer 14

-ventilate at 15:2 until igel in place
-once igel in place, give continuous compressions and ventilations
-Infants (u1yrs)- 25breaths per min (1 every 2 secs)
-1-8yrs- 20breaths per minute (1 every 3 secs)
-8-12yrs- 15breaths per minute (1 every 4 secs)
-12yrs+= 1 every 6 seconds

Question 15

IO access

Answer 15

-under 6yrs- distal femur
-6yrs+- prox tibia

-u1yr- 2ml initial flush, 10ml med flush
-1yr+- 5ml initial flush, 20ml med flush

If hypovolaemia is suspected during arrest give fluids 10mls/kg- LOOK AT PAGE FOR AGE ON JRCALC

Question 16

ROSC

Answer 16

-AVPU then normal A-E assessment with obs etc
-aim for ETCO2 of 4-4.5
-consider normal RR (as per page for age) and ventilate at that rate, adjusting for their etco2
-if low BP, give fluids unless given max dose
-NO POST ROSC ADRENALINE

Question 17

ROLE

Answer 17

-we don’t role paediatrics unless under specific guidance from a senior clinician on scene
-either we get ROSC
-or convey to hospital
-if improvement is looking unlikely consider senior clinical support or look to transport to nearest pead ED