PIRT Manual version 2.0 - Whole Manual copy

Paediatric Immediate Resuscitation Training

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1. Introduction to Paediatric Immediate Life Support

Learning Outcomes

To understand:

• The aetiologies of cardiorespiratory arrest in children

• The probable outcome of primary and secondary cardiorespiratory arrest in children

• How the anatomical and physiological differences in children changetheir management

Cardiorespiratory arrest is a rare event in children, and the outcome is generally poor. Out-ofhospital unwitnessed cardiorespiratory arrests have an extremely poor prognosis with only 8% of children surviving and most are neurologically impaired. The survival for in-hospital-arrests is better at 24% with a better neurological outcome. Over half of paediatric cardiac arrests occur in PICU where they have been monitored and witnessed. These generally have the best outcome because treatment is started early.

Aetiologies of cardiorespiratory arrest

The aetiology of cardiorespiratory arrest in infants and children differs from adults. This is due to differences in anatomy, physiology and pathology in children which alter as they grow and develop.

Adults tend to have primary cardiac arrests with a myocardial infarction leading to a fatal arrhythmia usually ventricular fibrillation (VF). This is usually a sudden unpredictable event, and successful treatment is dependent on rapid defibrillation.

Children tend to have secondary cardiorespiratory arrests due to hypoxia from an underlying illness which leads to respiratory and/or circulatory failure. Cardiorespiratory arrest occurs once compensatory mechanisms have been exhausted. This is generally not a sudden event; hypoxia leads to profound bradycardia which then deteriorates to asystole or pulseless electrical activity (PEA). Asystole or PEA is the initial cardiac rhythm in 85% of paediatric cardiac arrests. Recovery from this has a poor outcome because in the lead up to the cardiorespiratory arrest there is global hypoxia affecting all the vital organs. The signs and symptoms of respiratory and circulatory failure and the compensatory mechanisms can be detected using an ABCDE approach. Early recognition and treatment of respiratory and/or circulatory failure can prevent deterioration to cardiorespiratory arrest.

About 15% of cardiorespiratory arrests in children are due to a primary cardiac event. These children usually have underlying congenital heart disease (aortic stenosis, coarctation of the aorta), HOCM, a primary arrhythmia or myocarditis/cardiomyopathy.

Pathways to Cardiorespiratory Arrest

Anatomical and Physiological Differences

Airway

Smaller children have smaller airways which are more susceptible to obstruction, however there are other anatomical differences that increase the susceptibility to obstruction.

These differences are in the:

• Head and neck

• Face and mouth

• Nose and pharynx

• Larynx

Head and neck

Infants have large heads in relation to the rest of their body and the occiput is prominent. When placed on their backs the head tends to flex the neck which occludes the airway when conscious levels are reduced. As the child grows and develops the head becomes smaller in relation to the chest and the neck lengthens.

Face and mouth

The infant's face is small, so equipment needs to be suitably sized. The tongue is proportionally larger taking up more room in the mouth, this increases the likelihood of airway obstruction.

Nose and pharynx

Infants are obligate nasal breathers for their first 6-months, partial or complete nasal obstruction leads to airway obstruction and respiratory compromise

Larynx

In infants and small children, the larynx is higher in the neck and ellipsoid in shape not cylindrical as in adults. The epiglottis is larger and floppier. These differences mean that visualisation of the vocal

cords with a laryngoscope is different than in adults and the epiglottis is more prone to damage with airway devices and manoeuvres.

Breathing

There are several differences in young children with regards to breathing affecting:

• The lungs

• The mechanics of breathing

• The respiratory rate

The Lungs

The lungs are not fully developed until 2-years of age, and the resting lung volume and oxygen reserve are much smaller. Infants and young children have a higher metabolic rate and higher oxygen consumption. This means that oxygen reserves are used up very quickly, and oxygen saturations will fall very rapidly in respiratory compromise.

Mechanics of breathing

As children grow and develop the mechanics of their breathing changes. Infants and small children have a pliable rib cage and weak intercostal muscles. They are primarily diaphragmatic breathers with the diaphragm descending during inspiration creating a negative pressure in the chest and drawing air into the lungs. The intercostal muscles contribute very little to the mechanics of breathing. Anything that impedes the descent of the diaphragm, such as gastric or intestinal distension will impede respiration. The diaphragm tires suddenly which means that infants can suddenly become apnoeic. The pliable rib cage means that it is more likely to deform with increased respiratory effort in airway obstruction (bronchiolitis, foreign body obstruction) causing sternal, subcostal, and intercostal recession. This makes breathing less effective.

In older children the intercostal muscles become stronger and contribute more to the mechanics of breathing. The rib cage ossifies and is less likely to deform when there is difficulty in breathing due to airway obstruction. In children over 5-yr recession is an ominous sign indicative of serious airway compromise.

Respiratory rate

The tidal volume (TV) in children is 4-6ml/kg Infants have a high metabolic rate, oxygen consumption and carbon dioxide production, which is the main reason for their increased respiratory rate. Respiratory rate is also increased by fever, anxiety, agitation.

Respiratory rate with age:

Age RR

< 1 y 30-40

1-2 y 26-34

2-5 y 24-30

5-12y 20-24

>12 y 12-20

Circulation

There are several differences in young children with regards to circulation.

These are to do with:

• Circulating volume

• Cardiac output

• Blood pressure

Circulating volume

The circulating volume is proportionally higher at birth at 80ml/kg and decreases gradually throughout childhood until adult volumes of 60-70ml/kg are reached after puberty The absolute total circulating volume in infants, however, is very small for example a 5kg infant will have a circulating volume of 400ml whereas a 50kg teenager will have a circulating volume of 3,500ml. This means that relatively small volume losses in infants are a larger percentage of their total circulating volume. Children can compensate for up to 30-40% loss of circulating volume (see graph below) before their blood pressure falls

Haemodynamic response to hypovolaemia

Cardiac Output

Cardiac Output = Stroke volume x Heart rate

Stroke volume is the amount of blood ejected with each heartbeat and is very small (1.5ml/kg) at birth and is fixed; it increases with increasing heart size as the child grows. This means that the main determinant of cardiac output in small children is heart rate. An increase in heart rate will increase cardiac output whereas bradycardia will significantly reduce cardiac output. Heart rate is also increased by fever, anxiety, pain.

Normal range of heart rate with age

Age Mean

0-3 m 140 85 - 205 80 - 140

3 m-2 y 130 100 - 180 75 - 160

2 y-10y 80 60 - 140 60 - 90 >10y 75 60 - 100 50 - 90

Blood Pressure

Mean blood pressure (MBP) is dependent on cardiac output and systemic vascular resistance (SVR)

MBP = CO X SVR

SVR increases as a child grows and develops which is why blood pressure increases with age. Children can increase SVR to compensate for a reduced cardiac output to keep blood pressure and circulation. SVR cannot be measured and so this means that blood pressure is unreliable as a marker of cardiac output (see graph on previous page)

A blood pressure less than the 5th centile for age is a sign that tissue perfusion is inadequate and that the child is unable to compensate further.

5th centile blood pressure for age

BP mmHg 1 m 1 y 5 y 10 y 15 y

5th centile systolic 50 70 75 80 90

5th centile Mean 40 50 55 55 65

Disability

Disability is used to assess the neurological state of the child; in effect it is assessing the interactivity of the child with carers and healthcare professionals. Hypoxia and reduced brain perfusion affect the alertness and interactivity of children Infants and young children have limited communication skills and healthcare professionals must rely on adult carers to know if the child’s behaviour is normal for them. This may also be true for children with pre-existing disabilities. Children may regress developmentally if in pain, anxious, or unwell. Effective pain control, empathy and appropriate language are essential when assessing interactivity. The presence of parents or carers can ease anxiety and is to be encouraged.

Interactivity or conscious level can be assessed using the Glasgow Coma scale or AVPU scale (Alert, responsive to Voice, responsive to Pain, Unresponsive). Assessing pupil size and reactivity, the child’s tone and any abnormal posturing further assesses the neurological status.

Exposure

To ensure no significant clinical information is missed the child should be fully exposed. Small infants and children become cold quickly when exposed and so appropriate measure must be taken to minimise heat loss. Dignity must be maintained, and older children and teenagers may be shy and uncomfortable when undressed and exposed. They may also want to hide injuries particularly if selfinflicted.

Medication and Drug Doses

Drug doses and fluid requirements in children are based on their weight. In older and larger children, the recommended adult dose should not be exceeded.

It is often impractical to weigh an extremely sick infant or child and so the weight is often estimated.

If the child has recently been weighed and the weight is known use this otherwise estimate using any of the following:

• Age-Weight formula

• Infants at birth 3 - 3.5 kg

• Infants at 6-month 7 kg

• Children at 1 y 10 kg

• For children over 1-y Weight in Kg = 2 x (age + 4 )

• Paediatric emergency drug chart Monash charts etc.

• Body length tape Broselow tapes etc.

Key Learning Points

• The respiratory and circulatory anatomy and physiology of infants and young children influences the aetiology and management of their illnesses.

• Children are more likely to suffer a secondary rather than a primary cardiorespiratory arrest

• Successful resuscitation from respiratory arrest, where there is still a cardiac output, is associated with a better long-term survival.

• The mnemonic ABCDE is the basis for assessment and management of seriously ill children.

References

European Paediatric Advanced Life Support 5th Edition

Resuscitation Council UK

Paediatric Immediate Life Support 2nd Edition Resuscitation Council UK

Cardiopulmonary Arrest in Children

Roy M. Vega; Hersimran Kaur; Jun Sasaki; Peter F. Edemekong. Stat Pearls https://www.ncbi.nlm.nih.gov/books

Aetiology and outcome of paediatric cardiopulmonary arrest

Laura R. van Banning, Carrick. A.G. Allison Anaesthesia & Intensive Care Medicine Volume 21, Issue 12, December 2020, Pages 615-619

Cardiac arrest in children

Erika E Tress, Patrick M Kochanek, Richard A Saladino, Mioara D Manole J Emerg Trauma Shock. 2010 Jul-Sep;3(3):267–272

Images

Haemodynamic response to shock Shock in Pediatrics, Medscape htpps://ww.emedicine.medscape.com

Heart rate and Respiratory Rate graphs Spotting the Sick Child htpps://ww.spottingthesickchild.com

2. Recognition and Management of the Seriously Ill Child

Learning Outcomes

To understand:

• The importance of early recognition of the seriously ill child.

• The importance of a structured ABCDE approach to rapidly identify potential respiratory, circulatory, and neurological failure.

• The importance of a structured ABCDE approach to prioritise and assess the effectiveness of initial management strategies.

Early recognition of the seriously ill child

In children cardiorespiratory arrest is rare and is usually due to severe hypoxia, it reflects the body’s inability to compensate any further for the effects of the underlying illness. The initial problem may be due to an airway, breathing or circulatory problem but regardless of the aetiology cardiorespiratory arrest is seldom a sudden event. The child will compensate for the underlying illness but unless treatment is instituted will gradually deteriorate and decompensate as respiratory or circulatory failure worsens. Early recognition and effective management of respiratory and/or circulatory failure can prevent the deterioration to cardiorespiratory arrest. The use of an ABCDE structured approach helps to ensure that potentially life-threatening problems are identified and treated in order of priority.

ABCDE Approach

Paediatric early warning system charts such as RDR (Rapid Detection and Response Paediatric Chart), CEWT (Children’s Early Warning Tool) and PEWS (Paediatric Early Warning Score) aid detection of the deteriorating child and alert healthcare workers when and who to escalate concerns to

The ABCDE approach as detailed overleaf is a stepwise approach and can be completed rapidly, usually within 1-2 minutes.

General principles:

• Ensure personal safety and appropriate PPE

• Observe the child for overall level of illness Are they interacting normally with parents/caregivers?

• Speak to the child to assess level of responsiveness, ask parents about the child’s usual behaviour

• If not responding to voice administer a tactile stimulation, tug gently on their hair, squeeze the trapezius, or tickle their feet.

o If the child responds to voice or to tactile stimulation by crying or talking, they have a patent airway, are breathing and have cerebral perfusion.

o If there is groaning, grimacing or movement in response, rapidly assess using the ABCDE approach as below and

o Administer high flow oxygen immediately

o Attach monitors (ECG, SpO2, BP) early

o Gain circulatory access as soon as possible

• If the child is unresponsive check ABC and start BLS as necessary (see next chapter)

ABCDE Approach

An ABCDE assessment is easy to remember, it systematically and logically assesses for signs of respiratory, circulatory, or neurological failure and prioritises management interventions.

Assessment of the airway and breathing is essentially assessing oxygenation and ventilation; assessment of the circulation is assessing tissue perfusion including skin and kidney perfusion. Disability is assessing the effect oxygenation, ventilation and circulation are having on cerebral circulation and exposure may help in making a diagnosis of the underlying cause for the respiratory/circulatory failure.

System assessed

Assessing effectiveness of Airway Oxygenation and Ventilation

Breathing

Circulation

Disability

Exposure

Airway

Oxygenation and Ventilation

Perfusion

Effect of oxygenation, ventilation, and circulation on brain

Helps to make diagnosis to underlying problem

Airway obstruction will obviously lead to respiratory compromise and difficulty in breathing It can be partial or complete, sudden, or insidious, recurrent, or progressive. Initial partial airway obstruction can lead to increased work of breathing, respiratory failure, exhaustion, and secondary apnoea. Partial airway obstruction can rapidly become complete obstruction resulting in cardiorespiratory arrest.

Depression of the central nervous system and loss of consciousness can lead to loss of airway control.

Causes of airway obstruction

Airway obstruction partial or complete can occur anywhere in the airway from the nose to the trachea.

Nose

Congenital anomaly

• Choanal atresia

• Pierre-Robin Syndrome

Secretions

URTI

Nasal feeding tubes

Nasal cannulae

Foreign body

Oropharynx

URTI

Enlarged tonsils

Oedema

Foreign body

Loss of consciousness

Larynx

Epiglottitis

Laryngospasm

Foreign body

Trachea

Tracheitis

Foreign body

Recognition of Airway Obstruction

A child who is talking or crying has an open airway. Airway obstruction may be shown by difficulty in breathing, increased respiratory effort or noisy breathing. In a conscious child there may be obvious distress. Often conscious children with partial airway obstruction will assume a position that optimises their airway naturally such as neck extension or leaning forward and supporting themselves in a tripod position. Additional noises such as inspiratory stridor may be apparent in partial airway obstruction. Complete airway obstruction is silent. To assess the airway, look, listen, and feel for air movement and noises.

The smaller and younger the child the quicker they can go into respiratory failure. Babies under 3months are particularly vulnerable to hypoxia and apnoea.

Management of airway obstruction

Leave conscious children in the position they have adopted, leave them with their parents or care givers and administer oxygen in a non-threatening manner. Try not to make them cry as partial obstruction may become worse when they start to cry

In reduced level of consciousness airway compromise must be assumed. Partial airway obstruction may be relieved by head positioning (head-tilt chin-lift or jaw thrust), suctioning and by clearance of foreign bodies. Adjuncts may also be considered.

Breathing

Causes of breathing problems include:

Lung pathology

Congenital

Sequestration

Cysts

Atresia

Acquired

Bronchiolitis

Pneumonia

Pulmonary oedema

Asthma

Trauma

Neurological problems

Metabolic Problems

Respiratory Failure

Any impairment in breathing will cause the child to compensate for the deficit in ventilation and oxygenation.

• Compensated Respiratory Failure

This is a clinical state of an increased work of breathing or respiratory distress in an attempt to overcome a respiratory deficit

• Decompensated Respiratory Failure

This is when the child has lost the ability to maintain adequate blood levels of oxygen and carbon dioxide (i.e. in failure PaO2 < 9KPa, PaCO2 > 6.5KPa). It is recognised clinically to correspond to oxygen saturation (SpO2) < 90% in air.

Respiratory failure:

• Can exist with respiratory rates that are too fast or too slow, either will lead to a ventilationperfusion mismatch with reduced oxygenation.

• Can exist without respiratory distress in reduced level of consciousness, neuromuscular disease, and morphine/opiate overdose.

Assessment of breathing

Try to use a “hands off” assessment where possible. Allow the child to assume a position of comfort. Keep the child with their parents/caregiver. Try to assess with the chest exposed; the parents can lift clothing if necessary.

Ventilation

When assessing breathing we are in effect measuring minute ventilation.

Minute ventilation = Respiratory rate x Tidal Volume

Respiratory Rate

The respiratory rate easy to count and ideally should be assessed without disturbing or touching the child.As soon asthey start crying or coughing the rate will change It can be assessed from a distance ideally with the chest exposed but if this upsets the child this can be done through clothing. Assess for at least 30 sec.

The respiratory rate differs with age see below.

Age RR

< 1 y 30-40

1-2 y 26-34

2-5 y 24-30

5-12y 20-24

>12 y 12-20

Generally, the respiratory rate increases as an illness becomes more severe until decompensation occurs when the rate slows. This may happen suddenly. Respiratory rate is also affected by anxiety, pain, and fever.

Tidal Volume

Tidal volume is the amount of air that moves in and out with each breath. It can be assessed by looking at or feeling for chest expansion.

Assessing the effort of breathing

Normal breathing does not require any effort; increased work of breathing implies airway obstruction or underlying lung pathology.

Signs of increased work of breathing are:

• Recession

• Accessory muscle use

• See-saw respiration

• Nasal flaring

• Positioning

Recession

Recession or retractions means in-drawing of the muscles of the rib cage. Younger children show recession more easily and often due to their softer more compliant rib cages and chest walls. Recession can be difficult to pick up in chubby infants. Any recession in children over 5-y old is a sign of severely increased work of breathing. Recessions are usually assessed at the same time as measuring the respiratory rate.

Recession includes:

Tracheal tug which is a downward movement of the trachea on inspiration accompanied by drawing in of the supraclavicular structures.

Sternal recession where the sternum becomes depressed during inspiration. This indicates more severe respiratory distress because the sternum is a large bone and requires more effort to draw in on inspiration.

Intercostal recession is in-drawing of the muscles between the ribs, and subcostal recession is indrawing below the ribs

Accessory muscle use

Normally the main muscles of inspiration are the diaphragm and the intercostal muscles. Accessory muscles use refers to the use of sternocleidomastoid and scalene muscles during inspiration which when contracted lift the clavicles and first rib to expand the thorax. In babies this results in head

bobbing. With each breath the infant’s head bobs up and down. This makes breathing less effective and is a sign of severe respiratory distress.

See-saw breathing

This is a sign of severe difficulty in breathing and is sometimes called paradoxical breathing. On inspiration the chest is sucked in, and the abdomen expands, whilst on expiration the abdomen is sucked in, and the chest expands.

Nasal Flaring

Nasal flaring is seen more often in younger children and is where there is widening of the nostrils during inspiration which reduces airflow resistance at the nostrils.

Positioning

Patients with difficulty breathing are more comfortable upright. Tripod sitting refers to the position assumed when patients with breathing difficulties lean forward and rest their arms on their legs or the bed. This position helps the diaphragm move more efficiently and increases lung expansion as the accessory muscles are also used.

Tripod sitting

Respiratory noises

Listening to the chest particularly in infants and young children has less value than in adults. Children can become upset when a stethoscope is placed on their chest and start crying so it is impossible to hear any meaningful breath sounds. As their chests are small, noises tend to be transmitted all over making exact location of additional noises difficult.

Normal breathing is usually quiet Noisy breathing can happen for several reasons and can be classified as inspiratory or expiratory.

The following respiratory noises may be heard:

Wheeze, this is a high-pitched musical noise heard on expiration. It is due to lower airway narrowing and is heard in bronchiolitis and asthma. It can often be heard from a distance without a stethoscope. The loudness of the wheeze does not correlate with the severity of the underlying illness.

Stridor is a harsh sound heard on inspiration and is indicative of upper airway narrowing. It is heard in croup, foreign body obstruction, anaphylaxis, tracheitis, and epiglottitis. As with wheezing the loudness of the stridor does not correlate with the severity of the underlying illness. Do not examine the throat if you hear stridor.

Grunting is heard primarily in infants and is due to the infant breathing out against a partially closed glottis; this helps to keep their alveoli open during expiration and is a sign of significant respiratory distress. It is heard in bronchiolitis and RDS.

A silent chest is a medical emergency and is a sign that the tidal volume is very low.

Efficacy of breathing

Pulse oximeter

The pulse oximeter measures the amount of oxygen in the blood (SpO2) and is important for guiding management. It is useful as it is difficult to pick up cyanosis visually; most people cannot detect cyanosis until saturations are below 85%. Most children, especially babies and toddler, can appear fairly happy even with poor saturations. Normal children have saturations greater than 96%, less than 94% implies significant illness and should prompt supplementary oxygen use. Less than 92% is alarming and a sign of decompensated respiratory failure. The accuracy of the saturations detected is dependent on a good trace and will be falsely low if placed on a cold extremity or if the child is moving.

Effect of respiratory inadequacy on other body organs

Heart

There is often tachycardia to compensate for respiratory failure.

Skin

Hypoxia may lead to cyanosis or pallor

Brain

Hypoxia will lead to a reduced Level of consciousness

Management of respiratory compromise

The treatment of breathing problems is dependent on achieving a patent airway and effective delivery of oxygen. The method of oxygen delivery will vary according to the child’s clinical condition and age. Children with adequate spontaneous breathing should have oxygen delivered in a nonthreatening manner, which may be wafting oxygen, simple face mask or non-rebreathing face mask. Children with inadequate (or absent) breathing should have high flow oxygen delivered by bag valve mask ventilation.

Once problems with the airway and breathing have been managed the circulatory status should be assessed.

Circulation

Circulatory Failure

Circulatory failure is a clinical state where the flow of blood to the body tissues is inadequate for the metabolic needs of the child, and the removal of cellular waste is also inadequate.

Delivery of O2 = Hb x SpO2 x 1.34 x HR x SV

(Where – Hb=haemoglobin, SpO2=Oxygen saturation, 1.34=oxygen carrying capacity of haemoglobin, HR= heart rate, SV=stroke volume)

Delivery of oxygen to the tissues can be affected by changes to any of these parameters. The child has limited ability to compensate for a reduction in these parameters especially heart rate or stroke volume.

The commonest causes of circulatory failure are hypovolaemia, sepsis, and anaphylaxis. Less commonly it can occur with underlying heart problems such as cardiomyopathy or congenital heart

disease In cardiac tamponade and tension pneumothorax venous return to the heart is reduced and so the cardiac output is reduced, and when there is severe anaemia or carbon monoxide poisoning as the amount of oxygen carried by the blood is reduced.

Circulatory Failure

Circulatory failure can be compensated or decompensated.

In compensated circulatory failure there is preservation of blood flow to vital organs. This is maintained by an increase in cardiac output by increasing the heart rate (tachycardia) and by peripheral vasoconstriction. These together maintain perfusion to vital organs and maintain blood pressure.

In decompensated circulatory failure the circulation is unable to deliver oxygen to the tissues; the hallmark of decompensated circulatory failure is HYPOTENSION usually defined as a blood pressure less than the 5th percentile for age, this is usually accompanied by bradycardia.

BP mmHg 1 m 1 y 5 y 10 y 15 y

5th centile systolic 50 70 75 80 90

5th centile

Mean 40 50 55 55 65

Assessing circulation

Assessing circulation is essentially an assessment of cardiac output and delivery of oxygen and nutrients to the tissues.

Cardiac output (CO) = HR X SV

Oxygen delivery = Hb x SpO2 x 1.34 x CO

When assessing perfusion, it needs to be assessed peripherally, centrally and to the target organs (skin, kidneys, and brain)

Recognition of Circulatory Failure

Cardiovascular status is assessed by taking the following into account:

• Heart rate

• Pulse volume

• Capillary refill and skin colour and temperature

• Blood pressure

Heart rate

In hospital the heart rate is usually measured by a pulse oximeter or ECG electrodes although placement of these devices may make the child cry. It can also be measured by taking the radial or brachial pulse. The heart rate initially rises to maintain cardiac output, producing sinus tachycardia. Sinus tachycardia is also seen in response to fever, anxiety, or pain.

Age Mean Awake Asleep

0-3 m 140 85 - 205 80 - 140

3 m-2 y 130 100 - 180 75 - 160

2 y-10y 80 60 - 140 60 - 90

>10y 75 60 - 100 50 - 90

Decompensation occurs when tissue hypoxia and acidosis affect heart function and lead to bradycardia. Bradycardia is a pre-terminal sign.

Pulse volume

The strength of the pulse felt(pulse volume or amplitude) is dependant on the stroke volume of the heart. As the stroke volume decreases so does the pulse volume. Peripheral pulses (radial, dorsalis pedis) become weak before central pulses (brachial, femoral, and carotid) because increases in systemic vascular resistance cause peripheral vasoconstriction. It may be helpful to feel peripheral and central pulses simultaneously In infants and babies, the brachial and femoral arteries are central pulses and in older children the carotid and femoral pulses are central pulses. Diminishing central pulses is a pre-terminal sign.

Capillary refill, skin colour and temperature

The skin of healthy children is warm and well perfused unless the ambient temperature is cold. Measuring capillary refill time (CRT) is an effective way of assessing skin perfusion. It should be assessed centrally. To assess central CRT press on the centre of the sternum for 5-secs then release the pressure. Blanching should disappear within 2-secs in normal, well children. Delayed CRT indicates poor skin perfusion and implies that systemic vascular resistance is high to maintain blood pressure. Peripheral CRT can be delayed if ambient temperature is low. Skin mottling is also a sign of poor skin perfusion but is less specific than central CRT as it is affected by ambient temperature

Peripheral vasoconstriction also causes the peripheries to feel cool; often there will be a demarcation line between warm and cool skin. This will move towards the trunk as the child’s condition worsens and vice versa if improving.

Brachial pulse

Carotid pulse

Skin mottling

Blood pressure

Only when the body’s compensatory mechanisms of increasing heart rate, and vasoconstriction fail does the blood pressure fall, and decompensated circulatory failure occur. This is usually a late sign. In hypovolaemia blood pressure only falls once 30-40% of the child’s circulating volume has been lost (20-30ml/kg). Hypotension occurs earlier in sepsis and anaphylaxis. Blood pressure varies with age and hypotension is defined as a blood pressure less than the 5th centile for age as below:

For children over 1-yr this can be estimated using the following formula:

70 + (Age in years x 2)

Remember to measure blood pressure with the correct sized cuff; it should cover 2/3 of the length of the upper arm and the bladder of the cuff should cover 40% of the circumference of the arm.

HYPOTENSION is a pre-terminal event

Effects on other body organs

Respiratory system

The metabolic acidosis from circulatory failure leads to tachypnoea

Brain

Hypoxia and reduced brain perfusion lead to agitation and/or drowsiness eventually leading to hypotonia and loss of conscious. This can sometimes be difficult to appreciate in younger children and those with disabilities and so it is important to ask parents /caregivers if the child is behaving normally and responding to them normally.

Kidney

Reduced kidney perfusion will reduce urine output. Urinary output of less than 2ml/kg in infants and less than 1ml/kg in children is inadequate and a sign of reduced renal perfusion. In children who can use the toilet, reduced urinary output may be easily recognised. In babies and children in nappies the number and weight of the nappies gives an indication of urine output.

Management of Circulatory Failure

After ensuring that the airway is patent and that breathing is managed with high flow oxygen, intravascular access should be gained. This may be achieved with a large bore cannula intravenously or by inserting an intraosseous needle. Administer a 10ml/kg bolus of isotonic fluid (0.9% saline or a balanced solution such as Hartmann’s or Plasmalyte-148). If there is obvious on-going haemorrhage this should be addressed simultaneously with airway assessment and management.

Children with known cardiac defects should receive a smaller initial bolus of 5ml/kg.

After 30ml/kg of isotonic fluid boluses the use of inotropes should be considered.

Disability

Disability in the ABCDE framework is just a convenient word beginning with D which reminds you to do a neurological assessment. Following management of the airway, ventilation, and circulation the neurological status should be formally determined again. Respiratory and circulatory failure affect neurological function but some neurological conditions such as status epilepticus, raised intracranial pressure or meningitis can affect the respiratory and circulatory systems. When assessing the neurological status the following are assessed:

• Conscious level

• Pupils

• Posture

• Blood sugar level

Conscious level

This can be rapidly determined using the AVPU scale

A ALERT

V Responds to VOICE

P Responds to PAIN

U UNRESPONSIVE

If required a painful stimulus can be delivered by tugging on the child’s hair or by giving a trapezius squeeze. An alternative to the AVPU score is the Glasgow Coma score which has modifications for non-verbal children. P on the AVPU score is equivalent to 8 on the Glasgow Coma scale.

Drowsiness is commonly seen when children are febrile, and irritability is seen with meningitis or raised ICP.

Pupils

Pupils should be assessed for size and reactivity. Medicines and cerebral lesions can affect the pupillary responses. Unequal sized pupils may be due to raised intracranial pressure (ICP) or unilateral cerebral pathology.

Posture

Seriously ill children are hypotonic or floppy. Posturing which becomes evident when a painful stimulus is applied indicates serious brain dysfunction. Decorticate posturing where the arms are flexed and the legs extended or decerebrate posturing where there is extension of both the arms and leg can be seen.

Decerebrate posturing

Effects on other systems

Respiratory effects

Comatose children can show abnormal respiratory patterns such as Cheynes-Stokes respiration (alternate hyperventilation then apnoea) or complete apnoea

Circulatory effects

Raised ICP can cause Cushing’s Triad (bradycardia, raised blood pressure and irregular breathing) Cushing’s triad is a pre-terminal sign.

Blood sugar level

In any child with reduced level of consciousness blood glucose must be measured. This may be performed using a specific device or by assessing on a blood gas sample.

Exposure

To ensure that no significant clinical information has been missed the child should be fully exposed. This may give clues to the diagnosis e.g. rashes seen in meningococcal septicaemia, Group A strep sepsis and anaphylaxis, abnormal bruising seen in coagulopathy and non-accidental injury, fractures etc.

Careful attention must be paid to keeping the child warm especially infants and small children, and to respecting dignity in older children.

The temperature can be checked using an electronic tympanic thermometer. Alternatively axillary or oral temperature can be recorded using an electronic device or paper strips (Tempadots).

ABCDE Checklist

Assessment

On approaching Child

Airway

Breathing

Circulation

Disability

Information sought

General appearance:

Colour, tone, alertness

Interactivity with parent/caregiver

Is the airway:

Patent- talking or crying

At risk – noisy breathing, listless or reduced level of consciousness

Obstructed – quiet, reduced level of consciousness

Look, listen and feel for breathing

Respiratory rate

Chest expansion

Accessory muscle use

SpO2

Evidence of haemorrhage or fluid loss (vomit or stool)

Heart rate

Presence of peripheral pulses

Central pulse volume

CRT

Skin colour and temperature

Blood pressure

Urine output

AVPU score

Muscle tone

Posture

Pupillary size and reactivity

Possible actions

Suction

Head positioning

Airway adjunct

o oropharyngeal

o nasopharyngeal airway

Reassess

Call for help

Administer high flow oxygen

Wafting

Simple face mask

Non-rebreather mask

Bag-valve mask ventilation

Reassess

Call for help

Control external bleeding

Attach monitors

Gain intravascular or intraosseous access

Blood samples to laboratory or near patient testing

Blood glucose

Fluid bolus 10ml/kg

Reassess

Call for help

Check airway and breathing are being managed as conscious level dictates

Exposure

Ask if medication has been administered e.g. for seizures, overdose

Look for:

Haemorrhage

Bruises Rashes

Wounds

Fractures

Record Temperature if not already done so

Blood glucose if not already checked

Reassess

Call for help

Consider specific management such as blood transfusion, administration of antibiotics

Reassess

Call for help

Key Learning Points

• Early recognition of the seriously ill child prevents most cardiorespiratory arrests, thus reducing morbidity and mortality.

• The structured ABCDE approach ensures that potentially life-threatening problems are identified and dealt with in order of priority.

References

European Paediatric Advanced Life Support 5th Edition Resuscitation Council UK

Paediatric Immediate Life Support 2nd Edition Resuscitation Council UK

Spotting the Sick Child htpps://www.spottingthesickchild.com

Respiratory Assessment

Queensland Paediatric Emergency Care Skill sheet Htpps://www.childrens.health.qld.gov.au

Images

Respiratory system istock, istockphoto.com

Tripod position baby UAC Facebook

Tripod position child htpps://www.Medizzy.com

Tripod Position (epiglottitis) Htpps://www.medicalzone.net

Mottling of skin

Leg, DermNet htpps://www.dermnetnz.org

Baby htpps://www.community.babycenter.com

Arm

Diary of a Caribbean Med Student htpps://www.caribbeanmedstudent.com

Decerebrate and decorticate posturing The Ultimate Medical School Rotation Guide Chapter Neurosurgery pp845-927

Decerebrate posturing researchgate.net

Early onset of Fazio-Londw syndrome: the first case report from the Arabian Peninsula Mohammad Arif Hossain, Tariq Hazwani

3. Airway Management and Ventilation

Learning Objectives

• To understand the causes and management of airway obstruction

• To understand basic airway opening techniques

• To understand how airway adjuncts can maintain airway patency

• How to use bag-valve-mask (BVM) to effectively ventilate the lungs

Optimising airway patency and the provision of effective ventilation and oxygenation are central components in the management of critically ill children. Unless the airway is patent ventilation is impossible.

Causes of airway obstruction

Foreign body

• Small toys, food

• Mucus, blood, vomit

Loss of consciousness

The tongue falls backwards and occludes the airway, see below.

This occurs in:

• Hypoxia secondary to:

o Respiratory diseases

o Shock

o Cardiorespiratory arrest

• Neurological diseases

o Seizures

o Head trauma

o Intoxication

Recognition of airway obstruction

The most effective way to detect airway obstruction is to look, listen and feel for breathing.

LOOK for breathing

LISTEN for airflow at the mouth and nose

Look at the chest and abdomen

During normal breathing the chest expands, and abdomen is pushed slightly outwards If the airway is obstructed “see-saw” respiration may be visible where the chest is sucked in and the abdomen pushed out with each breath

Normal respiration is quiet

Breathing will be noisy in partial airway obstruction

Breathing will be silent in complete airway obstruction

FEEL for airflow at the mouth and nose

Conscious

child

Movement of air will be felt in normal and partially occluded airways

There is no movement of air felt in complete obstruction

In a conscious child, airway obstruction may be shown by difficulty in breathing with increased respiratory effort. They may look anxious, be tachypnoeic or have recessions. Breathing may be noisy with inspiratory stridor or wheezing.

Unless choking, conscious children will have an airway that is partially or completely open. In general children with partial airway obstruction will assume a position that optimises their airway naturally; they may tilt their head back or lean forward supporting their upper body (tripod). If the child is taking adequate spontaneous breaths, they should be supported in the position of comfort that they have adopted and left with their care giver This is particularly important in young children and babies as crying and distress can increase airway obstruction and may cause partial obstruction to progress to complete obstruction. High flow oxygen should be administered in a non-threatening manner that the child will tolerate. This may be by wafting oxygen, or using a simple oxygen mask, nasal cannula, or non-rebreathing mask. Further help from anaesthesia, and ENT should be sought in partial airway obstruction.

Unconscious

child

Whether or not an unconscious child is breathing the patency of their airway needs to be immediately optimised. There may be noisy breathing such as stridor or snoring indicating partial obstruction. Complete airway obstruction is silent. Partial airway obstruction can quickly deteriorate to complete obstruction. The airway can be optimized by simply repositioning the airway or by inspecting and suctioning the airway. If these measures do not clear the airway, adjuncts may be needed

Basic airway opening techniques

Repositioning the airway

This can be performed by using the head-tilt chin-lift position of by using a jaw thrust.

Head-tilt chin-lift

This involves gently tilting the forehead back slightly and lifting the chin which is supported by pressing on the bony part of the lower jaw

Infant

The neck should be in a neutral position neither flexed or hyperextended. In the neutral position the plane of the face is flat, with the tip of the nose pointing straight up. A rolled towel under the shoulders may help to maintain neutral position.

Child

The neck should be slightly extended with the nose “sniffing the morning air”.

Head tilt chin lift in an infant

Head tilt chin lift in child

Jaw thrust

This is the most effective airway opening manoeuvre in children and the preferred method if cervical injury is suspected. In this manoeuvre the rescuer approaches the child from behind, two or three fingertips of each hand are placed below the ears on the angles of the jaw. The thumbs rest gently on the cheeks. The fingers are lifted whilst downward pressure is applied with the thumbs to the cheeks. This moves the lower jaw forward/up and pulls the tongue and soft tissues up and out of the airway.

Suctioning

If airway obstruction is not relieved by repositioning the airway, the pharynx should be inspected as there may be a foreign body, blood, vomit, or mucus etc. causing obstruction. This will require a tongue depressor or laryngoscope so that the tongue can be pushed down and the back of the throat and pharynx can be properly examined. Suctioning the airway should always be performed under direct vision with a large bore suction catheter such as a Yankauer sucker. Only suck what you can see.

Jaw thrust in an infant

Jaw thrust in a child

Airway opening adjuncts

Airway adjuncts may be needed if positioning or suctioning of the airways does not relieve airway obstruction. The following airway adjuncts will be discussed:

• Oropharyngeal airway (OPA)

• Nasopharyngeal airway (NPA)

• Supraglottic airway (SGA)

Oropharyngeal Airway (OPA)

• An OPA may help to open the airway in an unconscious child who has no gag reflex.

• An OPA is a rigid curved tube designed to open a channel between the base of the tongue and the posterior pharyngeal wall. They are made of rigid plastic which is reinforced and flanged at the outer end.

• They are available in a number of sizes.

• The appropriate OPA size can be estimated by placing the airway concave along the side of the face and measuring from the central incisor to the angle of the jaw.

• The OPA can be introduced into the mouth in the position in which it will lie; a tongue depressor or laryngoscope may be needed to push the tongue down. Alternatively, they can be introduced upside down, pushing the tongue down, then rotated 180⁰ when halfway in and pushed further to lie in position.

• Following insertion, the flange should rest over the mouth and not protrude out of the mouth.

Nasopharyngeal Airway (NPA)

• The nasopharyngeal airway is a soft flexible tube designed to open a channel between the nostril and the nasopharynx.

Nasopharyngeal airway in situ

• They are bevelled at the insertion end and flanged at the outer end. If the outer flange is shallow, a safety pin can be fastened at the end of the tube to prevent them passing completely into the nose.

• NPA tubes are usually better tolerated by conscious or semi-conscious children. They are available in a number of sizes but generally do not cater for smaller paediatric patients. In which case a shortened endotracheal tube (ETT) can be used.

• The correct sized tube is estimated by measuring from the nostril to the tragus of the ear. The appropriate diameter can be estimated by measuring against the size of the nostril. The NPA should fit snuggly but not cause blanching of the nostril.

• To insert, the NPA should be lubricated, then inserted into the nostril in the direction that it will lie. With a gentle rotation motion the NPA should be passed directly backwards and posteriorly to sit in the nasopharyngeal space.

• Contraindications to using an NPA are facial trauma, basal skull fracture, coagulopathy, and nasal obstruction

Supraglottic Airway (SGA)

• Supraglottic airway devices sit above the larynx in the supraglottic space. They have a wide distal opening which may have an inflatable or mouldable gel cuff which creates a seal over the larynx. The cuff is connected to a semi-rigid tube that holds the airway open. They can be connected to ventilation devices. They were originally designed for use in surgery to deliver anaesthetic gases but have subsequently been found to be useful in managing the airway in cardiac arrest and resuscitation.

• In semi-conscious children with an intact gag reflex SGAs will cause gagging, coughing and laryngospasm so should only be used in unconscious patients.

SGA in situ

• There are now several types available the most widely used in resuscitation is i-gel®

Cuffed SGAs

i-gel® SGA

i-gel® SGA

• i-gel® is made from a thermoplastic elastomer which when warmed to body temperature moulds to the shape of the supraglottic space creating a seal. This has the advantage that the seal does not compress or cause trauma to the soft tissues of the airway.

• i-gel® are available in four sizes for use in paediatrics and the appropriate size to use is determined by the weight of the child. They are colour coded and are presented in a plastic cage which clearly shows the size of the i-gel®.

i-gel® size Weight Colour

1 2 -5 kg Pink

1.5 5 -12 kg Light blue

2 10 -25 kg Grey

2.5 25 – 35 kg White

• The size and weight guidance are also displayed on the i-gel® and should be visible to the rescuer when inserted.

• All i-gel® except the smallest size (size 1) have a gastric channel which allows for early warning of regurgitation and allows for a nasogastric tube to be passed.

• The i-gel® has an integral bite block.

• In trained personnel i-gel® can be inserted in less than 10-seconds. i-gel insertion technique

• Select the appropriate sized i-gel®

• Apply a small amount of water-based lubricant (such as optilube) to the distal tip and back of the i-gel®, taking care not to occlude the ventilation opening

• Hold the i-gel® in the dominant hand with the distal end which has the cuff facing toward the chin of the patient.

• Whilst standing behind the child position the head in the sniffing position. In infants a tongue depressor (or laryngoscope) may be needed to push the tongue down and out of the way.

• The tip of the i-gel® is inserted into the mouth and pressed against the hard palate.

Insertion into the mouth with head slightly extended

i-gel insertion in an infant using a laryngoscope to depress the tongue

• The i-gel® is gently advanced until the cuff passes beyond the tongue until resistance is felt

• The i-gel® should be secured in position with tape/ribbon

• Capnography and BVM can be attached to the connector on the tube

• Ventilate the patient, confirm placement by auscultation and chest rise

Oxygen delivery devices for spontaneously breathing children

In all seriously ill children oxygen should be given at the highest possible concentration as soon as it is available. Concerns about oxygen toxicity should not prevent its use during resuscitation. Oxygen flow should be regulated using a flowmeter capable of delivering 15L/min; ideally the oxygen should be humidified and warmed to minimise airway irritation and hypothermia. All children receiving oxygen should have oxygen saturations (SpO2) monitored and inspired oxygen titrated to maintain SpO2 94-98%.

The method and device for oxygen delivery should be determined by the clinical condition of the child. The following will be discussed:

• Blow-by oxygen

• Nasal cannulae

• Simple Oxygen mask

• Oxygen mask with reservoir bag (Non-rebreather oxygen mask)

Blow-by oxygen

This is also known as wafting oxygen and is the least threatening way to administer oxygen to young children. Oxygen tubing or a mask is held by the parents close to the child’s nose and mouth. The flow of oxygen is directed towards the child without contacting the face. There is no way of knowing how much oxygen is being delivered but is generally a low concentration; it is usually reserved for children with mild respiratory compromise. The effectiveness can be monitored by pulse oximetry

Nasal Cannulae

Nasal cannulae deliver oxygen to the patient via a thin flexible tube that goes around the head, and which has short prongs in it that fit into the nose. There are two types of nasal cannulae high-flow (HFNC) and low-flow.

Low-Flow Nasal Cannulae

Delivering oxygen via low-flow cannula is very useful for stable children of all ages particularly in preschool children. The delivery of oxygen is dependent on the oxygen flow rate and the nasal resistance. The maximum recommended oxygen flow rate is 4L/min. The amount of oxygen delivered is variable and cannot be precisely measured. It is not suitable for resuscitation. Nasal cannulae are also not suitable for children with copious nasal secretions as the prongs become blocked and then do not deliver any oxygen.

High Flow Nasal Cannulae Oxygen (HFNC)

HFNC delivers heated humidified oxygen at very high flow rates via a machine comprising of a flow generator, an air-oxygen blender, and a humidifier which warms the gases to 37⁰. See below

HFNC devices can provide flow rates up to a maximum flow rate of 60L/min in adults. In children the usual flow rates used are 2L/kg/min in children up to 12kg plus 0.5L/kg/min for each additional kilogram thereafter up to a maximum of 50L/min. Children can eat and drink whilst on HFNC and can ambulate.

HFNC have a number of beneficial effects on breathing including:

• Increase in functional residual capacity

• Improved mucociliary clearance of secretions

• Delivery of PEEP

HFNC are being increasingly used in the critically ill child to treat bronchiolitis, pneumonia, and lung contusion. They are not used in cardiorespiratory arrest.

Various machines are available including Optiflow, Airvo and Vapotherm (see below)

Optiflow

Simple Oxygen mask

Vapotherm

Simple oxygen masks are disposable clear plastic masks capable of delivering up to 60% inspired oxygen if flow rates are 10-15L/min. Room air is entrained into the mask and around the mask on inspiration diluting the amount of oxygen delivered.

Oxygen mask with reservoir bag (Non-rebreather oxygen mask)

This is the preferred method for delivering oxygen in the seriously ill child who is breathing spontaneously and can deliver up to 90% inspired oxygen. A clear disposable face mask is attached to a reservoir bag which is connected to the oxygen supply. The oxygen flow should be sufficient to inflate the reservoir bag and ensure that the bag does not collapse on inspiration, usually 1215L/min.

The mask is fitted with three one-way valves which ensure that the gases move in only one way and that rebreathing exhaled air or room air is prevented. The first valve is between the reservoir bag and the mask, and the other two are on each side of the mask on the inspiratory holes. During inhalation the valve between the reservoir bag and the mask opens allowing oxygen to flow into the mask. The valves on either side of the mask close and prevent room air from being drawn in. On exhalation the valve between the mask and reservoir bag closes whilst the other valves open to let the exhaled air to escape. If the side valves are removed a lower inspired oxygen is achieved as room air is entrained when the child breathes in.

Non-rebreather mask

Non-rebreather with side valves removed

Oxygen delivery devices for spontaneously breathing children

Methods of assisted ventilation

If a child stops breathing completely or spontaneous ventilation is inadequate positive pressure ventilation support is required. In a healthcare setting this will mean using a bag-valve-mask (BVM) device also called a resuscitator or Ambubag.

BVM devices are composed of a self-inflating bag, a non-rebreathing valve and a mask that conforms to the soft tissues of the face. The opposite end of the bag may be attached to an oxygen source and reservoir bag at 15L/min to deliver high concentration oxygen during resuscitation; without the oxygen source and reservoir bag ventilation will be delivered with air. The self-inflating bag can also be attached to an i-gel or endo-tracheal tube to deliver ventilation. A bag-valve-mask device cannot be used to deliver oxygen to spontaneously breathing patients.

When the bag is squeezed the air/oxygen in the bag is directed through the one-way valve. Provided there is a tightly fitting mask on the child’s face and an unobstructed airway the gases will inflate the lungs. Exhalation occurs through a one-way valve at the patient end of the bag. The bag automatically refills once it is no longer squeezed. Although the principle behind BVM ventilation is simple it is a skill that needs training and practice. Poor technique with an inadequate seal will lead to hypoventilation. During prolonged use in resuscitation the stomach becomes distended which can impede ventilation by pressing up on the diaphragm. A distended stomach will also increase the risk of regurgitation and aspiration. Insertion of a nasogastric tube may be required.

Bags

Self-inflating bags are available in a number of sizes depending on the manufacturer (250ml, 400500ml, and 900ml-1.6L). The medium sized 450-500ml bags are suitable for use in paediatric patients; although larger bags (900ml-1.5L) can be used if a smaller bag is not available. The pressure exerted on the bag should only be sufficient to support the tidal volume of the child and see chest rise. The 250ml bag is intended for use in neonates only. The bags used in infants and smaller children should have a “pop-off” pressure limiting valve which alerts the rescuer that excessive pressure is being delivered. The pop-off pressure is set by the manufacturers but is generally around 40 cmH2O. If required, the valve can be over-ridden but then excessive pressure may be delivered increasing the risk of pneumothorax.

Masks used with BVM devices

Masks used to deliver effective BVM should provide a good seal over the nose and mouth ensuring that there is minimal pressure on the eyes. Masks are available in two designs, circular and anatomically shaped, and in a number of sizes. Circular masks are recommended for infants and small children whilst anatomically shaped masks are more suitable for older children. Regardless of the shape, the mask must create a good seal.

Various shaped and sized masks

Correct positioning of the mask

Technique for BVM ventilation

• Having selected the appropriate sized mask, the rescuer stands behind the child.

• The oxygen supply should be connected to the self-inflating bag at 15L/min and the reservoir bag allowed to fill

• The child’s head should be in an appropriate position to open the airway.

• The mask should be applied to the face covering the nose and mouth

• Downward pressure is applied to the top of mask with the thumb and index finger, whilst the other fingers postioned along the bony part of the chin lift the jaw upwards into the mask.

• The bag is gently squeezed until chest expansion is seen.

• Once the chest is adequately inflated, the rescuer stops squeezing the bag and looks for the chest to fall.

• Repeat as required.

Single rescuers may find it difficult to maintain an air-tight seal and jaw thrust with one hand. If a second rescuer is available, the mask can be held with both hands of one rescuer whilst the second rescuer squeezes the bag. This does tie-up two rescuers in managing the airway, but the second rescuer can also perform chest compressions if required.

If chest expansion is NOT seen there are two possible reasons, either the airway is not patent or there is a leak. Recheck the airway and reposition or check for foreign body obstruction. Ensure that the mask is the correct size and that enough pressure is being applied to create a good seal. Reattempt ventilation once the necessary manoeuveres have been performed.

Key Learning Points

• Airway management and delivery of supplementary oxygen is the first priority in the management of critically ill children.

• Airway obstruction is commonly encountered in critically ill children and head positioning, or simple adjuncts may be required to optimise the airway.

• In spontaneously breathing children oxygen can be delivered using various oxygen masks or nasal cannula.

• Children who are not breathing or who are not breathing adequately require positive pressure ventilation initially with a resuscitator or BVM.

• Correctly performed positive pressure ventilation via a BVM is central to successful resuscitation.

References

European Paediatric Advanced Life Support 5th Edition

Resuscitation Council UK

Paediatric Immediate Life Support 2nd Edition

Resuscitation Council UK

I-gel Supraglottic Airway

Procedure Guidelines, Protopedia, roaddoc.com

The efficacy of oxygen wafting using different delivery devices, flow rates and device positioning

Denise F. Blake, Elizabeth M Shih, Paul Mateos, Lawrence H. Brown

Australasian Emergency Nursing Journal

Volume 17, Issue 3 August 2014 Pages 119-125

High-Flow Nasal Cannula

Sandeep Sharma, Mauricio Danckers, Devang K. Shanghavi, Rebanta K Chakraborty

StatPearls htpps://www.ncbi.nlm.nih.gov

High-Flow Nasal Cannula Oxygen Therapy Devices

Masaji Nishimura

Respiratory Care June 2019, 64 (6) 735-742; DOI: https://doi.org/10.4187/respcare.06718

Bag-Valve-Mask Ventilation

Joshua T Bucher, Rishik Vashisht, Megan Ladd, Jeffrey S. Cooper

Stat Pearls htpps://www.ncbi.nlm.nih.gov

Airway obstruction relieved by shoulder roll

Pediatric airway management

Harless J, Ramaiah R, Bhananker.

Int Crit Illn Inj Sci. 201;4(1):65-70. [PubMed] DOI: 10.4103/2229-5151.128015

i-gel paediatric range information sheet https://www.intersurgical.com

Images

Inserting i-gel

Resuscitation Council UK

NLS Provider Course, Airway Guide March 2022

Diagram of occluded airway child https://www.australiawidefirstaid.com.au

Non-rebreathing mask

Nasal cannula

St John’s Ambulance https://www.sja.org.uk

Non-rebreathing mask on child https://stevens.ca

Non-rebreathing mask on mannequin https://bmglobalsupply.com

Nasal cannulae on child https://www.hytape.com

Simple mask on child https://se.intersurgical.com

Simple oxygen mask https://www.medline.com

Bag-valve-mask resuscitator with pressure relief valve https://medbis.mediq.co.uk

BVM in use https://www.rch.org.au

NPA anatomy Bever Medical https://www.bevermedical.com

i-gel in situ https://www.intersurgical.com

Solus LMA https://www.intersurgical.com

4. Paediatric Basic Life Support

This guide is intended for healthcare professionals who have a duty to respond to cardiorespiratory arrest in infants and children in a healthcare setting.

Learning Outcomes:

• To recognise cardiac arrest in infants and children

• To understand how to activate emergency medical services

• To understand he rationale for the sequence of BLS

Good basic life support underpins advanced life support and should be performed whilst awaiting the arrival of advanced practitioners, equipment, and drugs.

Cardiorespiratory arrest in infants and children is rare but is usually secondary to an underlying disease process with respiratory failure or shock leading to hypoxia and asystole. Cardiorespiratory arrest is the end result of severe hypoxia and rarely a sudden unexpected event. Children with underlying heart problems however can have primary cardiorespiratory arrest due to a fatal arrhythmia which may be sudden and unexpected and require defibrillation.

Definitions

Infant refers to babies in the first year of life (0 – 12 months)

Child refers to children from 1-y up to puberty which has a variable age of onset and completion. If the rescuer thinks that the patient is a child, the paediatric guidelines should be followed.

Recommended Sequence for Paediatric Basic Life Support

The following sequence with the mnemonic DRS ABCD should be followed by first responder healthcare professionals in a healthcare setting:

Dangers

Responsiveness

Send for help

Airway

Breathing

CPR

Defibrillator

Dangers

• Ensure the safety of the patient and rescuers. In a healthcare setting it is rare for rescuers to come to harm during CPR however:

• Check for environmental dangers such as trailing wires, slip hazards from spilt liquids etc.

• Appropriate PPE should be used to reduce infection risk.

Responsiveness

It is important to establish the responsiveness of the unconscious child by using tactile and verbal stimulation. The method used will depend on the age of the child. In babies it can be achieved by talking to the baby or by gently touching or flicking their feet. In an older child it can be established by placing one hand on the child’s forehead and gently tugging their hair or squeezing their shoulders whilst saying “are you okay, wake-up.”

Never vigorously shake an infant or child.

• If the infant or child responds by crying, talking, or moving, leave them in a safe position. Call for extra help if necessary and regularly check on their condition whilst awaiting further assistance if required.

• If the child is UNRESPONSIVE

Send for help

• SHOUT for help, or pull/press the emergency buzzer

• The second responder should call 2222 stating location of cardiac arrest and team needed

Assess the child in the following order:

Airway

Open the airway; in an unconscious child with loss of muscle tone the tongue is likely to at least partially occlude the airway. Infants should have their head in the neutral position whilst older children should have mild extension of the head the so called “sniffing the morning air” position.

There are two ways to open the airway.

• Head tilt chin lift

Approach the child from the side, gently tilt the head backwards whilst holding the jaw (head tilt chin lift)

• Jaw thrust

Approach the child from behind and place both hands on either side of the child’s head.

Two or three fingers from both hands should be placed under the angle of the jaw just below the ears.

The thumbs should be placed on the child’s cheeks.

Gentle downward pressure on the cheeks and gentle upward pressure at the angle of the jaw will move the jaw up so that the lower jaw is in front of the upper jaw. This will move the larynx and open the airway.

INFANTS

Neutral position head tilt with chin lift

Jaw thrust

Head tilt with chin lift (sniffing the morning air)

CHILD

Once the airway is open inspect the mouth and remove any obvious foreign body if you are confident that it can be removed safely. DO NOT attempt blind finger sweeps as this is more likely to push a foreign body further into the airway and may cause complete obstruction to the airway.

Breathing

Assess for normal breathing and signs of life for no more than 10 seconds.

Signs of life include coughing and swallowing as well as breathing. The presence of a central pulse is a sign of life, but it can be difficult to detect even for experienced healthcare workers and unless a pulse rate greater than 60 bpm can definitely be felt within 10-seconds CPR should be commenced. Assess breathing by:

• Looking for chest or abdominal movement

• Listening for breath sounds at the nose and mouth.

• Feeling for airflow on your cheek.

Double handed jaw thrust

Agonal breaths or gasps are NOT normal breaths and should be treated as if the child is NOT breathing.

See-saw respiration (where the abdomen is pushed out and the chest sucked in with each breath) implies airway obstruction

If the child is breathing normally leave in a recovery position and check regularly whilst awaiting further help Consider further ABCDE assessment, oxygen, monitoring etc.

Recovery Position

• Aims to prevent airway obstruction and reduce the likelihood of aspiration

• The child should be turned on to their side with their mouth facing downward.

• Stabilise with pillow or rolled up towel along to prevent rolling from the side position.

• Reassess regularly.

If the child is not breathing give 2 effective breaths by bag-valve-mask ventilation (BVM). Use 100% oxygen if available. If BVM not available start chest compressions whilst awaiting ventilation equipment

If after the rescue breaths, there are no signs of life start CPR with chest compressions.

CPR

Method of compression

For effective chest compressions the child should be on a firm surface. There are differences in chest compressions between infants and children which are shown below.

Common features are as follows:

• Position

o Lower sternum one finger breath above xiphisternum

• Rate

o 100-120 compressions per minute

o 15:2 ratio. After 15 compressions give 2 breaths

• Depth

o 1/3 of the depth of the chest (4 cm infants, 5 cm children)

• Recoil

o Allow for adequate recoil, release all pressure on the chest between compressions, this is when the heart refills with blood.

Chest compressions in infants

There are two techniques using either thumbs or two fingers.

Two-Thumb technique

This is the preferred technique as it is more effective for the baby and less tiring for rescuers BUT does require two rescuers.

Technique:

• Place both thumbs flat side by side on lower sternum

• Encircle the lower part of the rib cage supporting the back

• Press down on the sternum with the thumbs

• Depress the sternum by one third of the depth of the chest (4cm)

Two-finger technique

This is the recommended technique for single rescuers but is more tiring for the rescuer.

Technique:

• Place two fingers (index and middle) of one hand on the lower sternum

• Depress the sternum by one third of the depth of the chest (4cm)

Chest Compressions in a child

Depending on the size of the child the rescuer may need to perform chest compressions with one or two hands. The rescuer positions themselves at the side of the child and the heel of the hand is placed in position on the lower sternum. The elbow is locked and the shoulders directly over the heel of the hand. The fingers should be raised off the chest. The rescuer uses their body weight to depress the sternum by a third of the depth of the chest (5cm) using one hand, or two hands which may be interlocked.

Single handed technique

Two-handed technique

Two-handed technique with fingers interlocked

After delivering 15 compressions give 2 breaths.

Continue until the child is responsive with return of normal breathing and other signs of life, or until more help arrives, or the rescuer becomes exhausted.

Chest compressions are tiring and as the rescuer fatigues compressions become less effective. If there is more than one rescuer swap roles to ensure effective compression every 2 minutes.

Defibrillator

Attach a manual defibrillator or AED to monitor the heart rate and rhythm. Use appropriately sized defibrillator pads if available. The majority of cardiorespiratory arrests in infants and children are secondary to hypoxia and defibrillation is not required, but the rhythm will be identified. In a witnessed sudden collapse, a primary cardiac arrest is likely which will require defibrillation.

An AED with a paediatric attenuator can be used in infants and children under 8-years, but if not available use a standard AED for all ages.

Universal sign for AED

The pads should be applied with minimal interruption to CPR, and prompts from the AED followed. CPR should be performed up to the point of analysis and immediately after the shock or no shock decision.

Key Learning Points

• Basic life support follows a stepwise approach

• DRS- Once ensuring safety of the patient and ascertaining that the child is unresponsive rescuers should summon aid then start BLS and:

• A - Open the airway

• B - Deliver 2 rescue breaths

• C - If no response start chest compressions with a ratio of 15 compressions: 2 breaths

• D - A manual or automated defibrillator should be attached and the rhythm assessed. If using an AED prompts should be followed

• BLS should continue until further help arrives or the child responds

References

ANZCOR Guidelines

Guideline 3 - Recognition and First Aid Management of the Unconscious Person

Guideline 12.1 - Paediatric Basic Life Support (PBLS) for health professionals

APLS Australia

https://www.apls.org.au

Algorithms

European Advanced Paediatric Life Support Manual 5th Edition Resus Council UK

Chapter 4 Basic Life Support

Clear airway Positional drainage or suction if available and trained to use

Resuscitation – Basic Life Support Algorithm

Collapsed infant or child

Ensure safety of rescuer(s)

Check Responsiveness - Squeeze, Shake & Shout

Infant = under 1

Child = 1 to 18

Shout for HELP! Pull emergency bell Request AED

Inspect airway for signs of obstruction –particularly stomach contents

OPEN AIRWAY

Head Tilt, Chin Lift (or Jaw Thrust)

Infant – neutral position; Child – sniffing position

Assess for signs of life (LOOK, LISTEN, & FEEL as appropriate to circumstance) Look for skin colour & chest rise; Listen for breathing and/or verbal sounds; Feel for air on cheek (if no IPC risk)

NO (or any doubt) YES

Presumed CARDIAC ARREST

Activate Emergency Team/Ambulance

Ensure emergency bag/trolley being collected

5 Rescue Breaths (look for signs of life whilst delivering breaths)

Reassess for signs of life

Assess A, B, C, D, E

Commence CPR 15 Chest Compressions (rate 100 – 120 compressions per minute)

CPR for 1 minute then reassess

Switch on AED and apply pads as soon as possible Follow AED instructions as appropriate Remember attenuated pads for less than 8 years old AED not recommended under 1 year of age

Continue until Advanced or Immediate Life Support available or patient shows signs of life and begins breathing normally

Follow relevant algorithm Reassess regularly

ConsiderRecovery position

Oxygen Monitoring

Handover to emergency team

5. Choking and Foreign Body Airway Obstruction

Learning Outcomes

• Recognition of airway obstruction

• The importance of early management of choking

• Differences in management of choking in infants and children

Choking occurs when the airway is completely or partially blocked making it difficult or impossible to breathe. It can occur with external pressure on the airway but is most often due to a foreign body lodging inside the airway when it is also known as foreign body airway obstruction (FBAO)

From about 9-months babies reach out for objects and start putting these in their mouth. This behaviour is called mouthing and generally continues until two years. Children are therefore at increased risk of choking between these ages. Children with developmental delay may continue to mouth objects for longer and so remain at increased risk of choking for longer. Small objects and toys such as marbles, Lego, hair bobbles, coins etc. can cause choking as can foods such as grapes, berries, raw carrot, sausages, chunks of meat, and round or hard lollies etc.

FBAO is characterised by the sudden onset of respiratory distress associated with coughing, gagging or stridor. Foreign bodies in the airway initiate a cough reflex which attempts to expel the foreign body, however, if the airway is completely blocked immediate assistance is required

If the airway is only partially blocked the child will usually be able to cry or vocalise and breathe. They may be able to clear the blockage themselves by coughing. In fact, a spontaneous cough is safer and generally more effective at clearing the airway than any manoeuvre a rescuer might perform. Do not attempt blind finger sweeps as these are likely to push the object further in to the airway. If an object is visible and you are confident that it can be removed with suction or Magill’s forceps attempt to remove it. Otherwise request urgent assistance from ENT and anaesthetics; allow the child to sit upright in a position they feel most comfortable and arrange urgent transfer to theatre for removal under direct vision.

If the blockage is complete the child will quickly become hypoxic and lose consciousness. They will require assistance to clear the blockage as will children with an ineffective cough for other reasons such as neuromuscular weakness.

Signs of choking

Witnessed episode

Sudden onset

General signs

Recent history of eating or playing with small objects

Drooling

Clutching neck with thumb and fingers

Ineffective cough

Distress, anxiety, agitation

Unable to vocalise

Quiet or silent cough

Unable to breath

Decreased conscious level

Cyanosis

Management of Choking

Effective cough

Distress, anxiety, agitation

Crying, talking

Loud cough

Able to breathe before coughing, stridor,

Fully responsive

Effective Cough

• Encourage coughing

• Observe closely

Ineffective Cough

Responsive

• Send for help, pull emergency buzzer.

• Call urgently for anaesthetics or ENT.

• Give five back blows, checking after each to see if an object has been expelled.

• If ineffective give five chest thrusts.

• Repeat sequence if needed

Infant

Technique for back blow

• Sit or kneel with the infant across your lap in in a head down prone position.

• Support the head by holding the lower jaw.

• Deliver five sharp back blows with the heel of the hand between the shoulder blades.

• Check if the object has been expelled after every back blow.

• If the object has not been expelled deliver five chest thrusts.

Technique for chest thrusts

• Turn the infant onto their back in a head down position. Place your arm along the infant’s back and hold the occiput/head with your hand.

• Identify the landmark for chest compressions (one finger’s breadth above the xiphisternum).

• Deliver chest thrusts which are like chest compressions but sharper and slower.

• Check after each thrust to see if the object has been expelled.

Continue to alternate back blows and chest thrusts until the object has been expelled or until the child loses consciousness when PBSL should be commenced.

Child

Technique for back blows

• A small child can be positioned across the rescuer’s slap or if larger supported in a head down position.

• Deliver five sharp back blows with the heel of the hand between the shoulder blades.

• Check to see if the object has been expelled after each back blow.

• If ineffective deliver five chest thrust.

Technique for chest thrusts

• Kneel or stand behind the child and support in a forward leaning position.

• Deliver thrust using the same technique as chest compressions but sharper and slower. Support the back during each thrust.

• Check after each thrust if the object has been expelled.

• Continue to alternate back blows and chest thrusts until the object has been expelled or the child loses consciousness, then start PBLS.

Key Learning Points

• Management of conscious choking infants of children consists of back blows followed by chest thrusts.

• Management of unconscious infants and children as a result of choking requires PBLS to be performed.

References

ANZCOR Guidelines

Guideline 4 – Airway

3.0 Recognition of Upper Airway Obstruction

4.0 Management of Foreign Body Airway Obstruction

Foreign Body Airway Obstruction Algorithm

APLS Australia

Algorithms Choking Child

Royal Children’s Hospital Melbourne ww.rch.org.au

Clinical Practice Guidelines Foreign bodies inhaled

Perth Children’s Hospital https://pch.health.wa.gov.au

Choking

CDC Nutrition www.CDC.gov

Choking hazards

Images

Choking infant and child Back blows and Chest thrusts Htpps://www.healthjade.net

Reference:

Soar J. et al (2020) Adult Advanced Life Support: 2020 International Consensus on Cardiopulmonary Resuscitation & Cardiovascular Care Science with Treatment Recommendations Resuscitation Vol 156; Pg A80 -A119

Resuscitation Council UK (2021) Advanced Life Support Manual 8th

Resuscitation – Choking (FBAO) Algorithm

Assess Severity

Infant = under 1

Child = 1 to 18

SEVERE AIRWAY OBSTRUCTION (Ineffective cough)

UNCONSCIOUS?

Shout for HELP! Pull emergency bell

CONSCIOUS?

UP TO 5 BACK BLOWS

OPEN MOUTH REMOVE OBVIOUS FOREIGN BODY

UP TO 5 CHEST THRUSTS (INFANTS)

UP TO 5 ABDOMINAL THRUSTS (CHILDREN) REASSESS

MILD AIRWAY OBSTRUCTION (Effective cough)

ENCOURAGE COUGHING

Continue to reassess for signs of deterioration or clearance of obstruction

OPEN AIRWAY REASSESS IF NECESSARY START BLS

Continue until Advanced or Immediate Life Support available or patient shows signs of life and begins breathing normally

6. Emergency Circulatory Access

Learning Objectives

To understand:

• The requirement for circulatory access during resuscitation

• The different routes of emergency circulatory access and their appropriate use

• Intraosseous access

During resuscitation access to the circulation is essential to obtain blood samples, which may give a clue to the reason for the arrest, and to be able to administer fluids and medication.

• Circulatory access can be obtained via the intravascular (IV) route or the intraosseous (IO) route.

• If there is a patent intravenous cannula in situ it can be used, but there may still be the need for additional access.

• In decompensated circulatory failure attempts at intravenous insertion should take no more than three attempts or 90-seconds. If access is not achieved within these limits intraosseous access should be gained.

• Intraosseous access is the recommended route of access in cardiac arrest.

• Any medication given intravenously through the intraossues route must be followed by a 25ml bolus of 0.9% saline.

Intravenous cannulation

Intravenous access can be gained peripherally or centrally. Central venous access is difficult to achieve in children and should only be attempted by experienced healthcare providers. This is usually the remit of the PICU team. Peripheral venous access should be a priority in unwell children. IV access is preferred to IO in children who are conscious.

Infants and children have small calibre mobile veins and are usually uncooperative and stressed during attempts at cannulation.

The following may help:

• Visualisation of veins can be improved by the use of trans-illumination, near infrared light or ultrasound

• Anxiety can be reduced by oral sucrose or breast-feeding in infants.

• Veins may be more filled and so more visible if a tourniquet is used, the vein is gently tapped, or by local warming

Sites for peripheral intravenous cannulation

Any peripheral vein can be cannulated, however, in seriously unwell children large easily accessible veins such as those in the antecubital fossa (cephalic or basilic veins) or the long saphenous in front the medial malleolus are best used.

Scalp veins should not be used for resuscitation because of the risk of extravasation and subsequent tissue necrosis. Their use may also interfere with management of the airway and ventilation.

Sites of peripheral veins

Intraosseous access

During resuscitation of cardiac arrest IO access is the emergency circulatory access of choice. In IO access the cannula is placed through the skin and into the medullary cavity of the bone. The medullary cavity is a non-collapsible vascular space and allows rapid delivery of fluids and medicines into the circulation.

Types of needles

Various types of intraosseous needles are available, including those for manual insertion, manualassisted or gun inserted and those for drill insertion. In most hospital settings a drill device such as EZ-IO is used.

Manual and gun assisted needles are available in various gauges for adult and paediatric use.

Manual insertion needles

Manual assisted needles

EZ-IO needles

EZ-IO needles are all the same gauge (15G) but vary in length, and colour. The smallest pink needle and middle-sized blue needle are recommended for use in children 3-39 kg, and the longest yellow needle recommended for patients 40 kg and over.

EZ-IO needles

Pain on insertion and use

Insertion of an IO needle can be painful although if a drill is used there is minimal pain. In conscious patients' local anaesthesia to the skin using lidocaine can be used prior to insertion. Instilling/injecting fluids or drugs into the medullary cavity of bone, however, is very painful and if the patient is conscious lidocaine should be instilled into the medullary cavity before injecting into the IO needle. The extension set can be primed with 2% lidocaine (20mg/ml) with a dose of 0.5mg/kg (0.25ml/kg) max dose 40mg (20ml.)

Advantages of IO access

• Ease and speed of insertion

o Success rates are higher than with iv placement (97% first attempt success rate)

o IO can usually be inserted in less than 10-sec

• Can be used to deliver all resuscitation fluids, medication, and blood products

• Allows rapid access of fluids and medicines to the central circulation

• It can be left in situ until intravenous or central venous access gained (max 48-hours)

Disadvantages

• Bone marrow is aspirated, not blood, and this cannot be used for analysis in point of care testing equipment such as blood gas analyser or blood glucose analyser. It can be sent to the laboratory, but the laboratory must be made aware that it is bone marrow.

• It can be painful to inject fluids/medicines in conscious/aware patients who may need local anaesthetic added to the infusion fluid.

• Force is required to inject medicines or fluids.

Contraindications

• Fracture of target bone

• IO attempted or placed in target bone within previous 48-hours

• Infection at insertion site

• Osteogenesis imperfecta or other bone abnormality

Complications

• Failure to enter the bone

o Extravasation which can lead to skin necrosis or compartment syndrome

o Subperiosteal infusion

Complications cont.

• Penetration through and through the bone

• Infection

o Osteomyelitis

o Local infection

• Growth plate injury

• Pain

• Bone or fat embolus

Sites of insertion

Upper humerus

Distal femur

• Midline above external epicondyle

Tibia

• Proximal tibia anteromedial surface below tibial tuberosity.

• Preferred site in cardiac arrest

• Distal tibia above medial malleolus

Insertion Procedure

Identify preferred site

Clean skin

Wear gloves and use a no-touch technique

If the patient is conscious use local anaesthesia to skin

Stabilise the limb

Select appropriate needle and attach to drill

Insert the needle into the skin at 90⁰ angle until the tip rests on bone

Ensure that at least one black line is visible (5mm) when the needle is touching the bone

Depress button on drill applying gentle downward pressure

Stop pressing the drill button once needle enters bone.

Usually a “give” is felt.

The needle should be almost flush with the skin

Hold the hub of the needle and remove the drill

Unscrew the stylet/trocar anticlockwise and remove Dispose of needle in sharps bin

Apply dressing over hub of needle

Attach primed extension set +/- three-way tap

Attempt to aspirate cannula, if unable to do so inject 2-5ml 0.9% saline flush and reattempt

Instil medicines or fluids as required under pressure

In conscious patient instil lidocaine before injecting fluids

Removal technique

Key Learning Points

Remove extension set and dressing

Stabilise hub of catheter and attach a luer lock syringe

Maintaining alignment twist clockwise and pull straight out

Dispose of catheter and syringe in sharps box

Apply dressing to insertion site

• Vascular access is required in the management of the sick child and in management of cardiorespiratory arrest

• Intraosseous access is the route of choice in cardiorespiratory arrest and in decompensated cardiorespiratory failure

• Intraosseous access is suitable for all fluids and medication required in cardiac arrest

References

Teleflex Arrow EZ-IO mobile phone app

Intraosseous access

Clinical Practice Guideline

Royal Children’s Hospital Melbournehttps://www.rch.org.au

Intraosseous Vascular Access

Peter Dornhofer, Jesse Z. Kellar Stat Pearls https://www.ncbi.nlm.gov

Intraosseous administration of preservative free lidocaine Great Ormond Street https://www.gosh.nhs.uk

Pictures

Cook intraosseous needle https://medtree,co,uk

Three EZIO needles https://www.medscape.com

EZIO drill and needles https://uslmedical.co.nz

EZIO in use

Diagram of bone https://www.slideserve.com

Veins of forearm and hand

Practical Procedures

Vessel Health and preservation 2: inserting a peripheral iv vascular cannula https://www.nursingtimes .net

Vascular access sites

Clinical Nursing Procedures: The Art of Nursing Practice 3rd Edition

Jacob Annamma, Tarachand Jadhav Sonali, R Rekha

Vascular access sites

Vascular Access: From Cannulation to Decannulation

Nissar Shaikh, Arshad Chanda, Adel Ganaw, Mohammad Sameer, Jazib Hassan, Muhmmad Waqas Farooqi & Mohammed Mohsin A. M. Haji

Vascular Access

Kelly Mayo & Joseph R Pare

7. Fluid Administration and Medication

Learning Outcomes

To understand:

• The type and volume of fluid to be administered in the emergency situation

• The indications, doses, and actions of first-line medication used in cardiorespiratory arrest

Fluid administration in resuscitation

During cardiorespiratory failure and arrest hypovolaemia is often a primary contributing factor and intravascular fluids are administered to restore circulatory volume to ensure adequate perfusion of vital organs.

The administration of fluids is essential for children showing signs of circulatory failure but fluid overload due to excessive administration can be detrimental. After each fluid bolus the child should be carefully assessed for signs of fluid overload. These signs are raised JVP (which is difficult to detect in babies) basal crackles and liver enlargement.

Fluid Volumes

An initial fluid bolus of 10-20ml/kg is recommended with careful reassessment after administration. If signs of circulatory failure persist a further bolus should be administered. If there are still signs of shock after administering 30-40ml/kg the child will need PICU support. Consider intubation and inotropes at this stage.

In cardiogenic shock and diabetic ketoacidosis fluids should be used cautiously and a smaller volume bolus is recommended. In cardiogenic shock consider using 5 ml/kg and in DKA start with 10 ml/kg.

Types of Fluid

Crystalloids

Crystalloid fluids are intravenous solutions that contain water and small water-soluble molecules such as electrolytes (e.g. sodium, chloride etc.) or glucose. They are cheap, readily available and do not cause allergic reactions.

Crystalloids can be isotonic, hypotonic or hypertonic. Isotonic solutions have an osmolality and sodium concentration similar to plasma and so do not cause big fluid shifts. Hypo or hypertonic solutions have a lower or higher sodium concentration and cause fluid shift; in some cases, this can have a therapeutic effect (3% saline to treat raised intracranial pressure) but fluid shift can also be detrimental to the child.

0.9% saline is an unbalanced isotonic solution containing only sodium and chloride ions. The sodium content is similar to plasma, but the chloride ion level is higher. Balanced isotonic solutions have sodium concentration similar to plasma but also have other electrolytes included in the solution such as chloride, potassium, magnesium, with concentrations similar to plasma.

In the initial stages of resuscitation unbalanced or balanced crystalloid isotonic solutions are the first line of treatment and should be used empirically. Glucose containing solutions should never be used for volume replacement as they can cause hyponatraemia and hyperglycaemia.

Appropriate crystalloids for volume replacement include:

• 0.9% saline

o Unbalanced solution contains only Na and Cl

o Can cause metabolic acidosis if large volumes given

o Cheap and readily available

• Plasmalyte-148

o Balanced isotonic solution (Also contains K, Mg and Lactate in addition to NaCl)

• Hartmann’s Solution

o Balanced isotonic solution (Also contains K, Ca and Lactate in addition to NaCl)

Colloids

Colloid fluids contain electrolytes and large molecular weight particles such as starches, gelatins, dextrans or proteins. In contrast to crystalloids, colloids are relatively expensive and can cause allergic reactions

Other than 4.5% human albumin solution colloids are rarely used in paediatrics and are not recommended as first line in resuscitation.

Blood Products

The use of blood products is reserved for specific indications such as blood loss or coagulopathy. In trauma with on-going blood loss “flying squad” uncross-matched O-negative blood or uncrossed group specific blood may be used as first line treatment

First Line Medication in cardiorespiratory arrest

Adrenaline 1:10,000

Indications for use

• Cardiorespiratory arrest

o Non-shockable rhythm give as soon as possible

o Shockable rhythm give after third shock

• Bradycardia - HR< 60pbm with signs of inadequate circulation

• Fluid resistant shock when it is given as a continuous infusion

• Anaphylaxis

Dosage

Cardiac arrest

0.1ml/kg of 1:10,000 (10mcg/kg) IV or IO.

Repeated every 3-5 minutes in non-shockable and shockable rhythms

Anaphylaxis

Given intramuscularly, strength is 1:1,000

Available as self-injectable device (Epipen, Anapen etc)

Dose is dependent on age as below:

Age Dose 1:1,000 ml (mcg)

< 6m 0.1-0.15 ml (100-150mcg)

6m-6y 0.15ml (150mcg)

6-12y 0.3ml (300mcg)

>12y 0.5ml (500mcg)

Actions

Adrenaline stimulates both alpha and beta e.

Stimulation of alpha receptors causes vasoconstriction and so increases diastolic and systolic blood pressure. This is thought to be the most important action in cardiac arrest as increasing diastolic blood pressure enhances coronary and cerebral perfusion.

Stimulation of the beta receptors increases the rate and force of contraction of the heart including the intensity of ventricular fibrillation which increases the likelihood of responding to defibrillation

Precautions

The effects of adrenaline may be reduced in an acidotic environment. Adrenaline is also inactivated by alkaline solutions and should never be given simultaneously with sodium bicarbonate. Administration should be via a separate cannula or followed by a 2-5ml flush.

Amiodarone

Indications for use

Shock resistant VF or pulseless VT

Dosage

5mg/kg maximum dose 300mg. Given after the third shock IV or IO

Actions

Membrane stabilising anti-arrhythmic

Precautions

Causes hypotension due to a mildly negative inotropic effect and vasodilatation. This is related to the rate of delivery. If given in VT with a pulse or SVT it should be infused over 20-minutes.

Lidocaine

Indications for use

Shock resistant VF or pulseless VT as an alternative to Amiodarone

Dosage

1mg/kg (max dose 100mg) IV or IO

Followed by an infusion

Actions

Anti-arrhythmic

Glucose

Indications for use

Hypoglycaemia - blood glucose < 3mmol/l

Dosage

2ml/kg of 10% glucose IV or IO

Sodium Bicarbonate

Indications for use

Sodium bicarbonate has a limited and unproven place in the management of paediatric cardiac arrest and is not a first line medication. It may be considered in severe metabolic acidosis (pH <7.1).

Dosage

0.5-1mmol/kg (0.5-1 ml/kg of 8.4% Sodium Bicarbonate)

Actions

Reverses blood acidosis but produces carbon dioxide which may worsen intracellular acidosis. May also can cause hypernatraemia and hyperosmolality depressing cardiac function.

Key Learning Points

• Fluid resuscitation starts with 10-20ml/kg bolus of an isotonic crystalloid such as 0.9% saline or Plasmaltye-148

• After each bolus the child should be reassessed to determine if further bolus is required.

• Once 30-40ml/kg has been administered consider intubation and use of inotropes.

• The main first-line medication in cardiorespiratory arrest is IV or IO adrenaline which can be repeated every 3-5 minutes if necessary.

References

Paediatric Immediate Life Support 2nd Edition Resuscitation Council UK

European Paediatric Advanced Life Support 5th Edition Resuscitation Council UK

Intravenous Fluid Management in Children

South Australian Paediatric Clinical Practice Guideline Department for Health and Wellbeing. Government of South Australia

Intravenous Fluid Bolus

Queensland Paediatric Emergency Care

Intravenous fluid therapy

Perth Children’s Hospital Government of Western Australia Child and Adolescent Health Service

Paediatric IV Fluid Prescribing Mind the Beep https://mindthebeep.com

ANZCOR Guideline 12.2 – Paediatric Advanced Life Support (PALS) https://www.anzcor.org

8. Defibrillation and Cardioversion

Learning Objectives

• To understand the indications for defibrillation

• To understand the indications for cardioversion

• Factors influencing the likelihood of a successful shock

• How to safely deliver a shock

Incidence of shockable rhythms

The initial rhythm in paediatric cardiac arrest is much more likely (80-90%) to be a non-shockable rhythm such as asystole or pulseless electrical activity (PEA), however a shockable rhythm such as ventricular fibrillation (VF) or pulseless ventricular tachycardia (pVT) occurs in 27% of paediatric inhospital cardiac arrests at some point during the resuscitation. The only effective treatment for VF or pVT is defibrillation which should be performed as quickly as possible. For every minute delay in defibrillating the chance of successful ROSC decreases by 10%.

Defibrillation

Defibrillation is a procedure where an electrical current is passed across the heart inducing global depolarisation and cardiac standstill. When the heart restarts the sinoatrial node is then able to reestablish sinus rhythm.

Defibrillation is delivered asynchronously in VF and pVT when it is important to deliver a shock as quickly as possible. An energy dose of 4J/kg is recommended for all shocks required to treat VF or pVT.

Defibrillators can also deliver a synchronised shock, where the shock is delivered at a particular point in the cardiac cycle. This is also called cardioversion. Synchronised shocks are used to treat supraventricular tachycardia (SVT) and ventricular tachycardia with a pulse (VT). Less energy is required for cardioversion which will be discussed later in this chapter.

Defibrillators deliver a biphasic waveform across the heart which is more effective and causes less myocardial damage than previously used monophasic waveforms. The shock is delivered via selfadhesive pads attached to the child’s chest. Self-adhesive pads do not move during chest compressions and enable defibrillation to be delivered at a safe distance from the child. Some pads also have sensors which can monitor the quality of the chest compressions being delivered.

Defibrillation is more effective if impedance to the flow of electricity is low.

Impedance is affected by:

• Pad size – the larger the pad the lower the impedance.

• Interface between the pad and the child’s chest – the pads should be applied firmly onto dry skin and smoothed to ensure no air is trapped underneath. Air will increase impedance.

• The position of the pads – the pads should “bracket” the heart.

• Chest wall thickness and obesity – impedance is lower when the distance between the pad and heart is short.

Types of defibrillators

Manual

Manual defibrillators require the healthcare worker to analyse the cardiac rhythm to determine if a shock is required. Manual defibrillators can deliver a full range of energy requirements, catering for all sizes of children, they can also be used for cardioversion. They should be available in all healthcare settings dealing with infants and children.

Automated external Defibrillator (AED)

AEDs are portable defibrillators available for public access and designed to be used by untrained rescuers. They are available in most public buildings including schools, sports centres, shopping centres, airports, and workplaces. The availability of an AED is indicated by easily recognisable signs which will give the exact location and may include other BLS advice (see below).

Once switched on an AED will give audible step-by-step instructions advising what to do. The AED will analyse the cardiac rhythm and determine if a shock is needed. The AED will only deliver a shock if it detects a shockable rhythm. If a shock is needed the device will charge and prepare to deliver a shock. AEDS are pre-set for the energy dose which is usually set for an adult. AEDS with attenuators which reduce the energy dose are available and are safe to use even in children under 8-years of age.

Defibrillator Pads

Defibrillator pads are self –adhesive and applied to the chest to deliver a shock. There are smaller pads available for infants, but adult sized pads can also be used with adjustment of positioning.

Position of the pads

The pads should bracket the heart and not touch one another. Although the pads are generally labelled right and left and may have a picture indicating the correct placement it does not matter if the positions are reversed.If placed on the “wrong side”, they should not be removed and changed as this wastes time and causes loss of adherence of the pad.

Positioning of pads

• Anterior- posterior

One pad is placed on the front of the chest over the sternum and the other pad on the upper back in the midline.

• Antero-lateral

Place one pad on the right side of the chest below the clavicle. The other pad should be placed on the lower left chest in the mid-axillary line.

Positioning of defibrillator pads

Infants

Anterio-lateral

Anterior-posterior

Children with implantable devices or pacemakers

Extra care needs to be taken when applying pads to children with implantable cardioverter defibrillator (ICD) devices or pacemakers and it is recommended that pads are placed at least 12cm from the ICD or pacemaker site.

Energy Levels

Manual defibrillator

An energy dose of 4J/Kg is used for all shocks. The exact energy dose for weight may not be available to select on the defibrillator in which case the next level up should be used e.g. for 12Kg child use

50J, as 48J is not available Adult doses are set by the individual defibrillator at 120-200J and should not be exceeded for larger children.

In refractory VF/pVT the energy dose may be increased to 8 J/Kg after the sixth shock, but expert advice should be taken before increasing dose. Adult doses should not be exceeded.

AEDs

The energy dose in AEDs is pre-set to adult levels unless the AED had an attenuator. The attenuator will lower the energy dose to 50-75J, and it is recommended that in children less than 8-years the attenuator should be used. If there is no attenuator adult energy doses can be used Children over 8years can be shocked at normal adult energy levels.

Timing of shock

A shock should be delivered as soon as a shockable rhythm has been identified. CPR should continue whilst the machine is charging to minimise time off the chest.

Safety

It is important to maintain safety to both the rescuers and patient during defibrillation and the following must be considered:

• Oxygen

Free flowing oxygen delivery devices (oxygen masks which may have been left on the bed) must be at least 1m away from the child. If the child is ventilated via a sealed airway (ETT/SGA) the ventilation bag or ventilator tubing can be left connected.

• Dry surfaces

Wet clothing should be removed and the child dried

• Contact with patient

The person delivering the shock is responsible for ensuring safety and must check that they, other rescuers and relatives are NOT in direct or indirect contact with the child during delivery of the shock. There should be no contact between the pads and any metal objects, or transdermal medication.

• Operator instruction

Operators must issue clear, audible instruction to the rest of the team and bystanders.

Sequence of actions for safe defibrillation

Manual Defibrillator

BLS should be ongoing then the following should be performed in this order:

• Confirm cardiorespiratory arrest – (5 s simultaneous breathing, pulse/signs life check.)

• Immediately continue CPR (15:2).

• Attach ECG monitoring /self-adhesive pads.

• Briefly pause chest compressions to analyse underlying rhythm (< 5 s).

• If ECG displays VF resume chest compressions apply self-adhesive pads to the chest (if not already done so).

• Team Leader hands over safe defibrillation to defibrillator operator who:

1. Selects appropriate energy (4 J/ kg).

2. Clearly states “Chest compressions continue”.

3. Instructs “Everyone else to stand clear and remove oxygen whilst charging”.

4. Charges defibrillator.

5. When charged, the rescuer in charge of the defibrillator, instructs the chest compression provider to “Stand clear, ready to deliver a shock”.

6. Checks that everyone is clear and that patient still in VF/pVT.

7. Presses button to deliver shock safely.

• CPR recommences immediately without checking for a pulse or reassessing the rhythm.

• After 2-minutes CPR the team leader prepares for next pause to check rhythm.

• If still in VF/pVT deliver 2nd shock.

AED

BLS should be ongoing then the following should be performed in this order:

• Confirm cardiorespiratory arrest – (5 s simultaneous breathing, pulse/signs life check).

• Immediately continue CPR (15:2).

• Switch on AED and attach self-adhesive pads.

• Await prompts from AED.

• Ensure that no-one touches the child whilst the AED analyses the cardiac rhythm and delivers a shock if required.

Cardioversion

Cardioversion is the timed delivery of an electric shock to the heart and is used in the treatment of VT with a pulse or decompensated supraventricular tachycardia (SVT). The shock is synchronised with the R wave of the ECG. The application of the pads and safety considerations are the same as with defibrillation as above, but the following differences apply:

• Sedation/anaesthesia will need to be administered as the child will be conscious, and cardioversion is painful and unpleasant if aware of it being performed.

• The synchronisation button on the defibrillator must be selected A marker appears on the R wave on the ECG indicating that the defibrillator is in synchronisation mode.

• The energy dose is lower than for defibrillation at 1J/Kg for the initial shock increasing to 2J/kg if the first shock is not successful.

• There is a delay in delivering the shock because of the synchronisation and so the button delivering the shock needs to be pressed for longer, until the shock has been delivered

• It is useful to have a continuous paper recording of the ECG running at the same time as the cardioversion as this can help the cardiologist to identify the underlying or provoking rhythm and the location of any recurrent entry pathway.

Key Learning Points

• Shockable rhythms occur in up to 27% of in hospital resuscitation attempts in children.

• For the child in VF or pulseless VT, defibrillation is the only effective way of restoring a spontaneous circulation.

• Manual defibrillators should be available in all healthcare facilities caring for children, but AED can be safely used in children.

• Use an AED if not confident with rhythm recognition.

• Energy dose for defibrillation shocks is 4J/kg.

• Energy doses for cardioversion are 1J/Kg increasing to 2J/kg if necessary.

• Chest compressions should be interrupted as little as possible during defibrillation.

• Good communication and teamwork is essential when delivering a shock.

References

ANZCOR Guideline 7 – Automated External Defibrillation in Basic Life Support https://www.anzcor.org

Paediatric Immediate Life Support 2nd Edition Resuscitation Council UK

European Paediatric Advanced Life Support 5th Edition Resuscitation Council UK

Defibrillation

Amandeep Goyal; Lovely Chhabra; Joseph C. Sciammarella; Jeffrey S. Cooper Stat Pearls, National Library of Medicine https://www.ncbi.nlm.nih.gov

Defibrillation in children

Haskell, Sarah E; Atkins, Dianne L

Journal of Emergencies, Trauma, and Shock 3(3):p 261-266, Jul–Sep 2010. | DOI: 10.4103/0974-2700.66526

Pictures Various AEDs https://defibsupplies.co.uk

Position of pads https://www.australiawidefirstaid.com.au

9. Rhythm Recognition

Learning Outcomes are to:

• Understand the normal ECG trace.

• Recognise cardiac arrhythmias associated with cardiorespiratory arrest.

• Understand how to manage bradycardia.

• Understand how to differentiate between sinus tachycardia (ST) and supraventricular tachycardia (SVT).

• Understand the priorities of management in children with compensated and uncompensated tachyarrhythmias.

ECG Monitoring

Once optimal ventilation and oxygenation have been established, all seriously ill children should have their ECG monitored. This allows for continuous monitoring of their heart rate and also allows for assessment of the heart rhythm.

The heart rate in children varies with age with younger children having higher resting heart rates. Heart rate will also vary with level of arousal, pain, fever etc.

See below for a guide to normal heart rate across childhood.

Age Mean Awake Asleep

0-3 m 140 85 - 205 80 - 140

3 m-2 y

2

- 180 75 - 160

Cardiac arrhythmias are rare in childhood and are more likely to be the result of an underlying illness rather than a primary cardiac abnormality. Children with acquired or congenital heart disease can however, present with a primary arrhythmia. Electrolyte disturbances and some medications or toxins can also cause arrhythmia in childhood.

Basic Electrocardiography

The ECG from lead II is usually selected on the cardiac monitor or defibrillator to assess the cardiac rhythm. The ECG trace represents the electrical activity of the heart. It does not reflect cardiac output and so the child’s clinical status needs to be assessed alongside the ECG trace. The electrodes can fall off mimicking asystole and vibrations transmitted to the leads may mimic VF.

Treat the child and not the trace.

Physiology

The electrical impulse for the heartbeat starts at the natural pacemaker of the heart, the sinoatrial (SA) node, which is in the right atrium. The impulse spreads to both atria stimulating atrial contraction.

The impulse reaches the atrioventricular (AV) node where there is a brief delay. This ensures that there is enough time for the atria to empty into the ventricles.

The impulse then spreads via the Bundle of His into the right and left bundle branches and into the Purkinje fibres deep in the myocardial cells. This causes contraction of the ventricles.

As the ventricles contract the AV valves shut, and blood is pumped from the right ventricle to the pulmonary artery and from the left ventricle into the aorta.

Blood in the pulmonary artery goes to the lungs where gas exchange takes place.

Blood in the aorta goes to the coronary arteries and systemic arterial system providing blood to the rest of the body.

The atria are filling whilst the ventricles are emptying in preparation for the next heartbeat. The ventricles, once empty, need to repolarise and relax so that they can fill ready for the next contraction.

Normal ECG

The normal ECG produces a trace on the monitor or on a paper record that is shown below. It consists of P, QRS, and T waves, and PR, QRS, and QT intervals.

The P wave represents atrial depolarisation and contraction

The QRS represents ventricular depolarisation and contraction

The T wave represents QRS repolarisation.

Standard ECG paper is composed of small squares, and the paper speed is 25mm/sec, so one small square represents 0.04 sec, and the larger squares which are five small squares represent 0.2 sec. On a paper recording every fifteen large squares (3 secs) there are triangular indicators at the top of the paper. Thirty large squares (or the time between 3 triangular markers) represents 6 secs. The heart rate can be calculated by counting the number of complexes in thirty large squares and multiplying by 10.

The ECG below shows a heart rate of 30 bpm.

Cardiac Rhythm Disturbance

Managing cardiac rhythm disturbance depends on four factors which are:

• Presence of a circulation

• Clinical status

• Heart rate

• Width of QRS complex

Presence of a circulation

ABCDE assessment can be used to determine if there signs of life and if there is a circulation with a central pulse palpable.

Absent pulse

The child is in cardiorespiratory arrest Start CPR and attach ECG monitor

Rhythms associated with cardiorespiratory arrest are:

VF or pulseless VT when the priority of management is effective CPR and rapid defibrillation.

VF

Or Asystole or PEA where the management priorities are effective CPR and adrenaline.

Asystole

Follow the ALS algorithm for shockable and non-shockable cardiorespiratory arrest. Consider and treat reversible causes.

If there are signs of life and a central pulse is palpable assess the child further as below to determine:

• Clinical status

• Heart rate

• Width of QRS complex

Clinical status

Determine if the child is in compensated or decompensated circulatory failure.

Compensated Circulatory Failure

The child will be conscious with a normal blood pressure for age. The ECG should be attached and the rhythm determined. As the child is stable there is usually time to gain intravenous access and seek expert help from a cardiologist. Anaesthetic help may also be required.

PEA

Decompensated Circulatory Failure

The child will have a reduced level of consciousness, prolonged CRT, weak/impalpable peripheral pulses and be hypotensive. An ECG should be attached, intravenous access attempted and expert urgent help from anaesthetics sought.

Heart rate

Varies with age but the defining heart rates are shown below:

Age Bradycardia Tachycardia

< 1yr < 80 bpm > 180 bpm

> 1yr < 60 bpm > 160 bpm

Bradycardia

The commonest cause of bradycardia is hypoxia and acidosis due to respiratory or circulatory failure. It may be a pre-terminal rhythm prior to cardiorespiratory arrest. If there are signs of decompensation, 100% oxygen should be administered, respiration supported and if the heart rate is less than 60 chest compressions started. Adrenaline should be given if there is no improvement with oxygenation and chest compressions.

Atropine should be considered if the bradycardia is likely to have been vagally induced by suctioning or intubation. Rarely pacing is required.

Tachycardia

Tachycardia can have a narrow or broad QRS complex. Usually, QRS lasts 1-2 small squares.

Narrow Complex Tachycardia

The two causes of narrow complex tachycardia are sinus tachycardia and supraventricular tachycardia (SVT).

Sinus tachycardia

Sinus tachycardia is a normal physiological response to anxiety, pain, or fever or arises to compensate for anaemia, hypovolaemia etc. In sinus tachycardia P waves will be clearly visible on the ECG. The onset is usually gradual and there will be some beat-to-beat variation in heart rate. In infants the heart rate is usually 180-220 bpm and in children 160-180 bpm.

The treatment of sinus tachycardia is treatment of the cause of the tachycardia. Treatment will result in a gradual reduction of heart rate.

Supraventricular Tachycardia (SVT)

In SVT the sinoatrial node is no longer acting as the pacemaker for the heart and there is usually an accessory pathway between the atria and ventricles. This pathway by-passes the AV node and transmits impulses more quickly than usual causing the tachycardia

In SVT the heart rate is normally very fast with rates greater than 220 bpm in infants and greater than 180 bpm in children. The onset is usually sudden, and P wave are not seen consistently on the ECG.

Compensated SVT can be treated with manoeuvres that increase vagal tone such as the diving reflex where a plastic bag filled with ice and water is placed on the infant’s or child’s face, or by wrapping the infant’s arms in a towel and immersing the whole face in an ice water slurry for 5-seconds. Older children can be asked to perform Valsalva manoeuvre by getting the child to blow through a straw or to attempt to blow the barrel out of a syringe. If these fail, then chemical or electrical cardioversion is required. If intravenous access is in situ and the child is still compensating, adenosine can be administered but if unsuccessful synchronised cardioversion will be required (starting dose 1J/kg increasing to 2J/kg) This will require anaesthetic support to ensure adequate sedation and analgesia.

Children who are decompensated should receive synchronised cardioversion. Anaesthetic support may be required to administer sedation and maintain the airway. Ketamine intra-nasally or intramuscularly should be used for sedation and analgesia if venous access is difficult as cardioversion should not be delayed.

Amiodarone may be required for refractory SVT, but expert cardiology guidance should be sought.

Broad Complex Tachycardia

Broad complex tachycardia is rare in childhood. There are two possible causes, ventricular tachycardia (VT) and SVT with aberrant conduction. Differentiation between these two rhythms is immaterial as they are both treated with synchronised cardioversion. Ventricular tachycardia is a broad complex regular tachycardia with no visible P waves. It can present with or without a pulse.

Treatment for VT with a pulse, is synchronised cardioversion. Amiodarone may be required for refractory VT, but expert cardiology guidance should be sought.

Pulseless VT is treated by defibrillation at 4J/kg as discussed above.

Drug treatment of arrhythmias

Key Learning Points

• In children life threatening arrhythmias are more likely the result rather than the cause of acute illness.

• The commonest arrhythmia seen in children is bradycardia and asystole as a result of hypoxia; oxygenation is the first line of treatment.

• Tachycardia may be narrow complex (sinus tachycardia or SVT) or broad complex (VT or SVT).

• SVT can be treated medically or by synchronised cardioversion depending on the clinical state of the child

• Broad complex tachycardia is always treated with synchronised cardioversion.

References

ANZCOR Guideline www.anzcor.org

Guideline 12.3 Management of other (non-arrest) arrhythmias in infants and children

European Paediatric Advanced Life Support 5th Edition

Resuscitation Council UK

Paediatric Immediate Life Support 2nd Edition

Resuscitation Council UK

Cardiology Teaching Package

Practice Learning Resources

The University of Nottingham www.nottingham.ac.uk/nursing/practice/resources

Cardiac Arrythmia Algorithm

[need to create algorithm]

10. Management of Cardiorespiratory Arrest

Learning Outcomes to:

• Understand the Paediatric Advanced Life Support Algorithm

• To understand how to recognise and treat non-shockable rhythms

• To understand how to recognise and treat of shockable rhythms

• Consider and treat the reversible causes of cardiorespiratory arrest

Resuscitation is a continuous process from basic life support to advanced life support. High quality basic life support provides the most important foundation for successful resuscitation.

All clinical staff within a healthcare facility should be able to:

• Immediately recognise cardiorespiratory arrest

• Start appropriate BLS with adjuncts if necessary

• Summon the clinical emergency team

The epidemiology, pathophysiology and aetiologies of paediatric cardiac arrest are different from adult or newborn cardiac arrests.

• Cardiorespiratory arrest in infants and children is usually secondary to hypoxia caused by an underlying respiratory illness or shock.

• Hypoxia affects all organs but in the heart leads to bradycardia, asystole, and PEA

• The outcome after successful return of circulation (ROSC) is poor as there has been preceding multi-organ hypoxia and dysfunction.

• There is less than a 5% survival rate without neurological sequelae following ROSC.

• As there is usually an underlying illness there is progressive deterioration with recognisable clinical signs; prompt medical interventions can prevent deterioration to cardiorespiratory arrest (See recognition of the seriously ill child).

Pathways leading to cardiorespiratory arrest

Emergency Teams

When a child suffers cardiac arrest in a clinical area staff should be able to promptly initiate BLS and summon the clinical emergency/resuscitation team. Appropriate equipment and trained staff should be available. Resuscitation teams will differ daily depending on rotas and working patterns. It is invaluable that the team “huddles” at the beginning of each shift to introduce themselves to each other, discuss the team member’s skills and assign roles. Huddles can also be used to identify patients at high risk of deterioration.

First Responders

All healthcare providers should be able to recognise cardiorespiratory arrest. A single rescuer must not leave the child but should start BLS and summon more help by shouting or pulling the emergency buzzer

As soon as a second rescuer arrives, they should be sent to activate the emergency team and return with readily available emergency equipment

Paediatric advanced life support (PALS) builds on high quality paediatric basic life support (BLS) which should be on-going.

Once the monitor/AED has been attached stop CPR briefly to assess the underlying heart rhythm and decide if the child is in a non-shockable (asystole, profound bradycardia or PEA) or shockable rhythm (VF or pVT) and treat according to the PALS algorithm as below.

Cardiac arrest rhythms

Non shockable

• Asystole

No electrical activity in the heart. “Flat lined”.

• Severe bradycardia <60pbm

• Pulseless electrical activity PEA (co-ordinated electrical activity on ECG but no pulse)

Shockable

• Ventricular fibrillation VF

Chaotic electrical activity “very funny”. Can be coarse or fine.

• Pulseless ventricular tachycardia pVT

Broad regular complexes. “Very tidy”. No pulse detectable.

Management

Non-shockable rhythms

Asystole PEA or bradycardia < 60bpm

Management

• Continue CPR with ventilation and chest compressions.

• Gain IV/OI access if no peripheral or central venous access already in situ.

• Administer Adrenaline 10mcg/kg (0.1ml / kg 1:10,000).

• Pause briefly every 2-minutes to check rhythm.

• If in VT or rhythm compatible with life, check a central pulse. If still in a non-shockable rhythm continue CPR, repeat Adrenaline (10mcg/kg) every 3 – 5 minutes.

Consider reversible causes 4 H’s & 4 T’s and treat

4 H’s

• Hypoxia ensure ventilating and giving oxygen.

• Hypovolaemia administer fluid bolus 10ml/kg of isotonic fluid.

• Hypo/Hyperthermia check temperature and warm or cool as required.

• Hyperkalaemia, Hypocalcaemia check electrolytes on blood gas and treat.

4 T’s

• Tension pneumothorax examine chest thoroughly. Signs of tension pneumothorax include tracheal deviation away from the side of the pneumothorax, hyper-expansion and hyper-resonance with reduced breath sounds on affected side. Immediate treatment is to perform needle thoracostomy in the 2nd intercostal space of the affected side. Follow up with insertion of a formal chest drain.

• Thromboembolism is rare in childhood, ECG and CXR may suggest PE.

• Toxins take urine for toxicology and treat as necessary.

• Tamponade can occur post cardiac surgery or with stab wound. It is diagnosed by echocardiogram or POCUS. Treatment is emergency pericardiocentesis.

Shockable Rhythms

These rhythms are more likely if there is an underlying cardiac defect, and if a primary event will cause sudden collapse; they can also arise during a resuscitation attempt. Rapid defibrillation is the key to ROSC and should not be delayed. For every minute delay in defibrillation the chance of successful ROSC decreases by 10%.

Management

• Administer DC shock of 4J/kg if using manual defibrillator. An AED can be used with or without an attenuator depending on age and size of the child.

• Resume CPR immediately after delivering shock. DO NOT pause for pulse check.

• After 2-minutes pause CPR briefly to reassess rhythm.

• If in VT or rhythm compatible with life, check a central pulse. If still in VF or pVT give a 2nd shock of 4J/kg and immediately resume CPR.

• Give Adrenaline 10mcg /kg 0.1ml/kg 1:10,000 (max dose 1mg i.e. 10ml) after the second shock.

VF pVT

• After 2-minutes pause CPR briefly to reassess rhythm. If in VT or rhythm compatible with life check central pulse. If still in VF or pVT give 3rd shock 4J/kg and immediately resume CPR.

• Give Amiodarone 5mg /kg (max dose 300mg) or Lidocaine 1mg /kg (max dose 3mg/kg up to 300mg) after the 3rd shock.

• Continue to give Adrenaline 0.1ml /kg 1:10,000 every 3-5 minutes (every second shock/alternate cycles) and to deliver shocks every 2-minutes whilst the child remains in a shockable rhythm.

Consider reversible causes 4 H’s & 4 T’s and treat.

General Considerations

Airway management

The majority of children can be adequately ventilated with BVM in the initial stages of resuscitation; insertion of a supraglottic device (laryngeal mask airway or igel®) is generally achieved quickly and easily and so should be considered if anaesthetic help is not immediately available. Once medical staff skilled in intubation is available intubation may be attempted as long as it does not interfere with oxygenation and chest compressions. Tracheal intubation is the most reliable way to secure an airway, once an endotracheal tube is in situ chest compressions can be performed continuously provided that they do not interfere with delivery of ventilation breaths.

Ventilation rates vary with age and the following is recommended during resuscitation.

Age Rate/min

Infants 25

1-8 y 20

8-12 y 15

>12y 10 - 12

End-tidal carbon dioxide detection (calorimetric or capnographic) must be continuously monitored once an SGA or ETT is in place.

Oxygen

100% oxygen should be used to ventilate the child during CPR.

Chest compressions

Compressions should be performed:

• at a rate of 100-120 per minute

• at a depth of 1/3 of the chest (infants 4cm, child 5cm)

• allowing for full recoil

• using a ratio of 15:2 (compressions: breaths) unless intubated when they may be continuous

• with minimal pauses, which should be planned

High quality chest compressions are important to maximize the chances of CPR but are very tiring. The quality of chest compressions deteriorates when rescuers fatigue and so it is recommended to change the person performing chest compressions every 2-minutes.

Vascular access

Vascular access will be required for administration of medicines and fluids.

Use existing peripheral or central lines if in situ and patent. If not insert an intravenous cannula. If after 3 attempts or 90 seconds a cannula has not be sited insert an intraosseous cannula.

Consider reversible causes 4 H’s and 4 T’s and treat as above.

Stopping Resuscitation

The decision to stop resuscitation should be based on a combination of factors including:

• Pre-arrest status and likely outcome:

o In some cases, such as terminal cancer, when death is inevitable continuing CPR is futile.

o Children with other life-limiting conditions or severe disabilities may not survive further tissue or brain damage.

• Duration of arrest and response to resuscitation:

o In infants and children, the cause of cardiorespiratory arrest is usually progressive hypoxia and hypotension causing irreversible damage to all of the organs and it is unlikely that ROSC will be achieved after 30-minutes of continuous good quality CPR.

o Prolonged resuscitation may be performed in infants and children with hypothermia or those in persistent VF or pVT.

o Prolonged resuscitation may be considered in cases of poisoning whilst awaiting response to a specific treatment or anti-toxin.

• Remediable factors:

o Reversible causes (4H’s and 4T’s) should have been considered and treated.

• Opinions of experienced personnel:

o The team leader is usually the most experienced member of the team and ultimate responsibility to stop resuscitation will lie with them, however, the decision to stop should be the collective decision of the whole team.

• Wishes of the parents or guardians:

o Resuscitation may be continued whilst awaiting the arrival of the parents or guardians.

o The wishes of the parents must be asked for and considered, however, the final decision regarding stopping lies with the team leader.

• Availability of ECMO:

o This can provide on-going life support if there is severe lung disease which is reversible.

Presence of Parents during resuscitation

The opportunity to be present during the resuscitation of their child should be offered to all parents. Studies have shown that it helps with the grieving process. If parents are present the following should be considered:

• A specific member of staff should remain with the parents to offer support. An interpreter may also be required.

• Physical contact with their child should be encouraged as long as it does not interfere with the resuscitation.

• If resuscitation is unsuccessful parents should be given the chance to say goodbye to their child.

Debrief of rescuers

Children in cardiac arrest always test the readiness, skills and abilities of individuals and organisations. A cardiac arrest may be sudden and unexpected or may result from a preventable deterioration of a child’s condition, and can also result following a mishap. Following a resuscitation, a debrief discussion should take place as soon as possible with everyone involved. This allows for the team to reflect on their actions and identify areas for improvement. The psychological impact of the events surrounding cardiac arrest of a child on healthcare staff should not be ignored and a separate debrief to share personal feelings and reactions with others and to vent emotions may be held separately.

Documentation

One member of the team should be allocated the role of scribe during the resuscitation to record timings and doses of medications etc. After the resuscitation the team leader should carefully document the resuscitation sequence of events and response to treatment with help from the scribe and other members of the team.

Team members should be listed with their responsibilities and timing of events should be recorded as accurately as possible.

Key Learning Points

• Paediatric cardiorespiratory arrest is usually secondary to hypoxia or shock which leads to bradycardia or asystole.

• Asystole is a non-shockable rhythm, and successful resuscitation depends upon high quality CPR and the administration of adrenaline.

• Shockable rhythms such as ventricular fibrillation and pulseless ventricular tachycardia are much rarer in childhood but do occur. Successful resuscitation depends upon timely defibrillation with high quality CPR. Medication may be required if the arrhythmia does not immediately respond to defibrillation.

• Reversible causes should be considered and treated during resuscitation for both shockable and non-shockable rhythms.

• Parents should be encouraged to be present during resuscitation of their child.

References

ANZCOR Guideline www.anzcor.org

Guideline 12.2 Paediatric Advanced Life Support (PALS)

European Paediatric Advanced Life Support 5th Edition

Resuscitation Council UK

Paediatric Immediate Life Support 2nd Edition

Resuscitation Council UK

British National Formulary for Children BNFC

https://bnfc.nice.org.uk

Resuscitation – Advanced Life Support Algorithm

Child/Infant unresponsive & not breathing normally Basic Life Support Algorithm

Commence CPR Chest Compressions (15:2 once BVM available) (rate 100 – 120 compressions per minute)

Shockable (VF/ pulseless VT)

During CPR

1 Shock 4j/kg or AED (attenuated as appropriate)

Immediately resume CPR 15 Chest Compressions: 2 Ventilations FOR 2 MINUTES Minimise interuptions

• Ensure good quality CPR –rate, depth, recoil

• Plan actions before interrupting CPR

• Give oxygen

• Attempt/verify IV/IO access

• Give adrenaline 3 – 5 minutes (10mcg/kg, 1:10,000)

• Correct Reversible Causes (see below)

• Consider advanced airway (LMA)

• Give uninterrupted compressions when airway secure

•Consider: ➢ amiodarone after 3rd shock if available

REVERSIBLE CAUSES Hypoxia Tension pneumothorax

Hypovolaemia Tamponade, cardiac

Hypo/hyperkalaemia/metabolic Toxins Hypothermia Thrombosis (cardiac or pulmonary)

Consider ultrasound imaging to identify reversible causes ALL REVERSIBLE CAUSES SHOULD BE EXCLUDED OR TREATED WHERE POSSIBLE

Activate emergency team/ambulance service

Infant = under 1 Child = 1 to 18

Non-Shockable PEA/Asystole)

Immediately resume CPR 15 Chest Compressions: 2 Ventilations FOR 2 MINUTES Minimise interruptions

If ROSC achieved:

Assess patient A, B, C, D, E

Post event ECG

Secure additional access

Consider catheterisation

Aim for SpO2 of 94 – 98% and normal PaCO2

Targeted Temperature Mgt

Contact relatives

Remember care of family

Rhythm analysis

11. Management of Common Medical Emergencies in Children

Learning Outcomes

• Identify common paediatric illnesses

• Understand how the ABCDE approach to assess common paediatric illnesses guides initial treatment

The illnesses and emergencies covered are:

• Anaphylaxis

• Asthma

• Sepsis

• Seizures

• Hypoglycaemia

Anaphylaxis

Anaphylaxis is a severe, whole body, potentially life threatening, allergic reaction. It accounts for 20 deaths per year in Australia and can happen very quickly, usually within minutes of contact with an allergen. The diagnosis is made clinically as there is no diagnostic test for anaphylaxis. The commonest allergens that cause anaphylaxis in children are foods, medicines, or insect stings. The only effective treatment for anaphylaxis is Adrenaline: once diagnosed it should be promptly treated with Adrenaline. If in doubt give Adrenaline.

Pathophysiology

Exposure to a triggering allergen leads to release of histamine and other mediators from mast cells in the skin, gut, heart, blood vessels and respiratory tract. The chemical mediators include histamine and r. There is also stimulation of the production of prostaglandins, leukotrienes, and cytokines. These mediators lead to smooth muscle contraction and increased vascular permeability leading to tissue oedema, bronchospasm, and distributive shock. Symptoms may be mild or moderate at first but quickly worsen to a severe reaction. Anaphylaxis can be fatal if not treated promptly with food allergens causing death within 30-minutes, insect stings within 10-15 minutes and by intravenous medication within 5-minutes. Food is the commonest allergen causing anaphylaxis in children.

Commonest allergens causing anaphylaxis.

Source of allergen

Commonest allergens

Food Peanut, tree nuts, cow’s milk, egg, fish, sesame seeds, shellfish, wheat, mustard, soya, celery

Medicine

Antibiotics (Penicillins, Cephalosporins)

Anaesthetics, muscle relaxants

NSAIDs

Chlohexidine

Insect stings Bee sting

Others

Latex, exercise, idiopathic

Symptoms of anaphylaxis include:

• Hives, welts or generalise erythema

• Swelling of the face, eyes, lips, and tongue

• Tingling of the mouth, tightness in the throat

• Difficulty breathing, stridor, wheeze

• Abdominal pain and vomiting (in insect stings)

• Dizziness or collapse

Recognition of Anaphylaxis ABCDE Approach

Airway

• The airway may be at risk because of swelling to the tongue and throat.

• There may be a hoarse voice or stridor due to laryngeal oedema.

Breathing

• There are usually signs of increased work on breathing with tachypnoea, recession, or tracheal tug.

• There may be respiratory arrest.

• Wheeze is heard on auscultation. Although wheeze the hallmark of asthma it may also be heard in bronchiolitis, foreign body aspiration and anaphylaxis. The volume of the wheeze does not directly correlate to the degree of airway narrowing and an increase in the volume may indicate improvement in their condition. A very quiet wheeze or SILENT chest is an ominous sign.

• Reduced oxygen saturation or cyanosis.

Circulation

• There will be tachycardia with signs of shock such as cool peripheries and prolonged CRT.

• Blood pressure will be low and may cause dizziness, collapse, or cardiac arrest.

Disability

There may be confusion, agitation or loss of consciousness

Exposure

There may be hives, wheals or urticaria. Skin changes are often the first sign to be present but can be subtle. The rashes are intensely itchy.

ACTIONS

Remove the suspected allergen, if possible, then treat lie-threatening features.

Airway

• Open the airway

Breathing

• Give 100% oxygen via non-rebreathe mask or support ventilation with BVM

Circulation

• Do not allow the patient to stand, they should lie flat or sit.

• GIVE INTRA-MUSCULAR(IM) 1:1,000 ADRENALINE and repeat every 5-minutes if features do not resolve. The dose may be drawn from an ampoule or given from an auto-injector device (Anapen or EpiPen).

Dose of adrenaline

Age Wt Kg

1-5y 7.5-20 150 0.15

5-12y 20-50 300 0.3

>12 >50 500 0.5

IF IN DOUBT GIVE ADRENALINE

10% of cases of anaphylaxis require a second dose of Adrenaline.

• Gain intra-venous or intra-osseous access.

Give 10ml/kg bolus of balanced isotonic fluid or 0.9% saline. Repeat as required.

Note Antihistamines are not recommended for the treatment of anaphylaxis. They may be useful for cutaneous symptoms of itching after stabilisation.

Corticosteroids are not recommended for the treatment of anaphylaxis, but they may be useful after stabilisation or in refractory shock.

The diagnosis of anaphylaxis may be confirmed by measuring serum mast cell tryptase immediately after the event, 1-2 hr after and at 24 hr.

All patients requiring Adrenaline should be observed in hospital for at least 4-hours after treatment. After discharge they should be referred to a specialist allergy clinic for an anaphylaxis action plan and an adrenaline auto-injector prescription.

Anaphylaxis Action Plan

Refractory Anaphylaxis

Anaphylaxis is said to be refractory if on-going treatment is required after 2 doses of intra-muscular adrenaline. Expert help will be required. Treatment consists of repeated IM adrenaline and fluid bolus until an intravenous low-dose adrenaline infusion via a peripheral vein can be started. Ongoing respiratory support may require nebulised salbutamol, BVM or intubation.

Asthma

Asthma is a common chronic inflammatory disease of the lungs. The inflammation leads to variable airway obstruction due to excessive mucus production and hyper-responsiveness of the smooth muscle in the airways. In childhood it can cause mild daily symptoms such as cough but for most children it is episodic with “acute asthma attacks” causing cough, shortness of breath, chest tightness and wheeze.

8.7% Australian children under the age of 15-y have asthma (411,000 children) with 42% of them having to take time off school because of their asthma.

Acute asthma can be life-threatening; cardiac arrest can be caused by hypoxia, tension pneumothorax, or by arrhythmias due to drugs or electrolyte imbalance.

Intubation and mechanical ventilation can be very difficult in acute asthma, so it is important to treat promptly before there is respiratory failure or arrest.

Recognition of Acute Asthma ABCDE Approach

Airway

• Usually open but can become at risk of obstruction if conscious level reduced.

Breathing

During an acute asthma attack there will be:

• Signs of increased work on breathing with tachypnoea, recession, or tracheal tug.

• Wheeze is heard on auscultation. The volume of the wheeze does not directly correlate to the degree of airway narrowing and an increase in the volume may indicate improvement in their condition. A very quiet wheeze or SILENT chest is an ominous sign.

• Reduced oxygen saturation or cyanosis.

Severity of acute asthma

Mild/Moderate Severe Life-Threatening Can walk, speak in whole sentences

SpO2 >94%

Circulation

Unable to speak in sentences Visibly breathless Increased WOB

SpO2 90-94% in air

Drowsy Collapse Exhausted Poor respiratory effort

SpO2 <90%

• May have compensatory tachycardia but may be normal.

Disability

• There may be confusion, agitation, or loss of consciousness due to hypoxia.

Exposure

• The child may be febrile if infection has triggered the acute attack.

ACTIONS

Airway

• Open airway

Breathing

• Apply pulse oximeter

• Give oxygen 15l/min via non-rebreathe mask or support ventilation with BVM

• Give Salbutamol ± Ipratropium by MDI or nebulised with oxygen and review. Repeat as required

• Give oral or intra-venous steroids

• Consider Magnesium Sulphate, intravenous Aminophylline or Salbutamol if little response to nebulised salbutamol. See table below.

Circulation

• Gain vascular access for medication

Summary of Treatment Acute Asthma

Mild/Moderate Severe

Can walk, speak in whole sentences

SpO2 >94%

Salbutamol MDI

Repeat every 20-30 mins

Steroids

Unable to speak in sentences Visibly breathless

Increased WOB

SpO2 90-94% in air

Salbutamol MDI

Ipratropium MDI OR

Salbutamol/Ipratropium nebulised in O2

Repeat every 20- mins

Steroids (Prednisolone)

Magnesium Sulphate i.v. Aminophylline or Salbutamol

Life-Threatening

Drowsy Collapse

Exhausted

Poor respiratory effort

SpO2 <90%

Salbutamol/Ipratropium nebulised continuously

Steroids (hydrocortisone)

Magnesium sulphate Intubation

Sepsis

Infections are the most common reason for children to attend the emergency room. Most infections are mild viral self-limiting illness with fever; some are more serious such as bacterial infections of the respiratory tract e.g. pneumonia or urinary tract infection e.g. pyelonephritis.

Sepsis is defined “a life-threatening organ dysfunction caused by a dysregulated host response to infection”. The immune system essentially goes into overdrive and the body’s inflammatory response to an infection injures its own tissues and organs. Viral, bacterial, and fungal infections can lead to sepsis.

Sepsis is more likely to affect very young children especially those less than one year old.

The first stage of sepsis in children can be difficult to distinguish from simple infection. Sepsis, however, quickly leads to shock, multiple organ failure and death if not promptly recognised and treated. Even if treated promptly 50% of sepsis survivors have long term sequelae. Most countries now have a national sepsis programme and toolkits such as “Sepsis Six” to help with early identification and management.

Pathophysiology

• An infection triggers a local inflammatory response.

• Release of inflammatory mediators (TNF, interleukins, prostaglandins from WBC and macrophages) cause systemic inflammatory response syndrome (SIRS).

• The mediators activate coagulation and inhibit fibrinolysis leading to microvascular thrombosis which impairs oxygen delivery to tissues leading to organ dysfunction.

• The mediators also cause vasodilatation and dysfunction of the vascular endothelium which leads to distributive shock.

• The mediators may also have a direct effect on the myocardium causing cardiogenic shock.

• The overall effect is sepsis and septic shock

Sepsis can be diagnosed if there is evidence of infection plus at least two of the following:

• Altered mental state

• High or low temperature >38.5⁰C or <36.0⁰C

• Tachycardia

• Tachypnoea

• Reduced peripheral perfusion

• High or low WCC >12x109/l or <4.0x109/l

Recognition of sepsis ABCDE Approach

Airway

• At risk of obstruction if level of consciousness reduced.

Breathing

• Signs of increased work on breathing with tachypnoea and recession. This may be due to the underlying triggering infection (pneumonia) or as a compensatory response to shock.

Circulation

There may be signs of shock with:

• Tachycardia

• Weak peripheral pulses and pallor

• Cool peripheries and prolonged CRT

• Hypotension

Disability

• AVPU. There may be an abnormal conscious level due to the underlying condition (meningitis) or due to hypoxia resulting from respiratory or circulatory failure.

• Hypogylcaemia is a feature of sepsis

Exposure

• The temperature may be high (>38.5⁰C or low < 36.0⁰C).

• There may be rashes giving a clue to the underlying diagnosis e.g. petechial or purpura in meningococcal infection, erythema of toxic shock (staphylococcal, streptococcal infection)

Meningococcal infection

Toxic Shock Syndrome

ACTIONS

Summon senior help

Airway

• Open airway if necessary

Breathing

• Give oxygen by nonrebreather mask

• Support ventilation with BVM

• Attach cardiorespiratory monitoring

Circulation

• Gain vascular access- intravenous or intraosseous

• Take blood for blood culture, FBC, Lactate, CRP, LFT, UEC, venous blood gas, blood glucose, and clotting

• Give broad spectrum antibiotics as per hospital guidelines (generally Ceftriaxone, or Cefotaxime)

• If lactate greater than 2 mmol/l give 10ml/kg bolus of balanced crystalloid or 0.9% saline. Carefully reassess after each bolus. If more than 40ml/kg has been given and normal physiology has not been restored start inotropes adrenaline infusion is first line inotrope and should be administered in a dedicated line.

• Call for anaesthetic support as it is likely that the patient will need to be transferred to PICU and require intubation.

• Monitor urine output and send sample for MC&S.

Sepsis six Toolkit

Seizures

Seizures are common in childhood; most are short-lived and self-terminating lasting a few seconds or 1-2 minutes only. Seizures lasting more than 5-minutes are less likely to stop spontaneously and are more likely to lead to neurological sequelae, treatment should be started after 5-minutes.

Convulsive status epilepticus is now defined as a single generalised seizure lasting more than 5-minutes or two or more discrete seizures between which there is incomplete recovery of consciousness.

Pathophysiology

Causes of CSE include:

• Febrile seizures

• Epileptic syndromes

• Metabolic abnormalities including hypoglycaemia and hypocalcaemia

• CNS infection

• Brain tumour

• Intracranial haemorrhage or stroke

• Hypoxia

• Shock including septic shock

Recognition of Convulsive Status Epilepticus ABCDE Approach

Airway

• At risk of upper airway obstruction due to secretions, tongue/soft tissue hypotonia or loss of protective reflexes.

Breathing

• Airway obstruction or reduced level of consciousness can lead to respiratory failure.

• Slowing of the respiratory rate because of the seizure or because of treatment may also lead to respiratory failure.

Circulation

• Not generally affected until respiratory failure occurs.

Disability

• Hypoglycaemia may be the cause of the seizure. Always measure in seizing patients.

• If blood glucose <3mmol/l give 2ml/kg of 10% dextrose.

Exposure

• May give a clue to diagnosis if rashes present suggesting meningococcal disease

• There may be evidence of head trauma with bruising of the scalp, or bleeding from the ears

ACTIONS

Airway

• Open the airway. Consider NPA.

Breathing

• Give oxygen via non-rebreathe mask with 15l/min of oxygen

Circulation

• Establish vascular access intravenous or intraosseous

Disability

• Treat hypoglycaemia if detected.

• Seizures should be treated with anti-epileptics once they have continued for more than 5minutes. Use a personalised protocol if this available, otherwise give benzodiazepine (diazepam, lorazepam or midazolam) by quickest available route rectal, intravascular, buccal or nasal). Repeat benzodiazepine after 5-minutes if seizure continues. The second dose may be a different benzodiazepine and given by an alternative route. Do not give more benzodiazepine doses; two is the maximum recommended as respiratory depression is very common with more doses.

• If the seizure does not stop give a second line agent. All second line agents are equally effective, but Levetriacetam is easier to give and has a better safety profile.

• If the seizure continues administer an alternative second line agent and call for anaesthetic support.

• If the seizure continues rapid sequence induction of anaesthesia will be required with thiopentone or propofol and the child will need intubation.

• Consider neuroimaging when stable.

Hypoglycaemia

Clinical hypoglycaemia is defined as a blood-glucose concentration low enough to cause symptoms or signs of impaired brain function. It is generally accepted to be a blood glucose level of less than 3.3mmol/l in non-diabetic patients. A higher level of less than 3.9mmol/l is generally used for people with pre-existing diabetes.

Hypoglycaemia is the result of an imbalance between glucose supply, glucose utilisation, and existing insulin concentration.

An altered conscious state or seizure warrant prompt blood glucose assessment and management with a bolus of IV 10% Dextrose (2 mL/kg) or IM glucagon if less than 3.3mmol/l (3.9mmol/l in diabetics).

Prolonged or recurrent hypoglycaemia, especially with clinical features, can cause long term neurological damage or death.

Glucose homeostasis

Glucose is the primary source of fuel for all the body’s cells. It is the primary energy source for both anaerobic and aerobic metabolism. The brain can store only trivial amounts of glucose in the form of glycogen There are several different metabolic pathways that maintain glucose homeostasis to ensure a continuous supply of glucose for optimal functioning of the brain

In response to fasting key changes in the endocrine system are triggered, these are:

1. Decrease in insulin secretion

2. Increase in glucose production via several counter-regulatory hormones including glucagon, cortisol, growth hormone and adrenaline which affect the liver causing:

• Increase in glycogenolysis where glycogen is broken down to glucose

• Increase in gluconeogenesis where new glucose is formed from lactate, glycerol, and amino acids

• Lipolysis and ketogenesis where fat is broken down to make ketones and free fatty acids beta-hydroxybutyrate and acetoacetate.

Ketones can be used by the brain as an energy source. As glucose production declines and ketones increase, the brain gradually switches to ketones as its primary fuel. It is important to note that although ketone bodies can act as a complementary energy source in times of glucose shortage, they do not replace the need for glucose; they take time to generate and, at higher levels, are associated with ketoacidosis.

Infants and younger children have a 2-3-fold higher glucose use rate than adults and fewer glycogen stores so that interruption of glucose delivery can have devastating consequences on the developing brain and can cause permanent brain injury. Infants and children can also use ketones for cerebral metabolism.

Pathophysiology of Hypoglycaemia

Non-diabetic Children

The imbalance between glucose supply, glucose utilisation, and existing insulin concentration can be due to a number of reasons including:

Age Causes

Neonate-2y

Congenital hyperinsulinism (most common cause of persistent hypoglycaemia <2 yrs)

Inborn errors of metabolism (Fatty Acid Oxidation disorders, Glycogen Storage Disorders)

Congenital hormone deficiencies (eg growth hormone deficiency)

Child Accelerated starvation (previously known as “ketotic hypoglycaemia”)

Hypopituitarism

Growth hormone deficiency

Accidental ingestions (alcohol, sulphonylureas, beta-blockers, aspirin)

Adolescent Insulinoma

Adrenal insufficiency

Eating disorders

All ages Other illness (e g sepsis, congenital heart disease, tumour, adrenal insufficiency)

Symptoms of hypoglycaemia include:

• Palpitations, tremor, anxiety, sweating, hunger, paraesthesia

• Lethargy, irritability, uncharacteristic behaviour, hypothermia, confusion, coma, seizures

Recognition of Hypoglycaemia ABCDE Approach

Airway

• At risk of obstruction if level of consciousness reduced.

Breathing

• There may be respiratory depression if reduced level of consciousness

Circulation

• Tachycardia, sweating

Disability

• Tremulous

• AVPU in severe hypoglycaemia the level of consciousness will be reduced

• Blood glucose <3.3mmol/l

Exposure

• Temperature may be normal or raised.

ACTIONS

Airway

• Open the airway

Breathing

• Support breathing with BVM and oxygen if required

Circulation

• If conscious and able to swallow they may be treated with concentrated oral glucose solution (40% glucose gel) e.g. Glucogel, Dextrogel

• If unconscious gain vascular access and give 2ml/kg bolus of 10% dextrose

• If unable to gain vascular access give intramuscular glucagon

• Monitor blood glucose

Further blood tests will be required to determine the cause of the hypoglycaemia. These should be directed by the metabolic team, but the following are usually required:

• Plasma glucose

• UEC, LFT

• Growth hormone

• Insulin and C-peptide

• Ketones (Beta-hydroxybutyrate)

• Free fatty acids

• Lactate

• Ammonia

• Cortisol

• Carnitine/Acyl carnitine

• Amino acids

Diabetic Patients

Common clinical precipitants for hypoglycaemia in children with diabetes may include:

• Insufficient food consumption (i.e. missed meals, nocturnal hypoglycaemia), excessive insulin dosing,

• Exercise,

• Alcohol ingestion (in adolescents), and

• Sulfonylureas [unlicensed].

Recognition of Hypoglcaemia

As above except <3.9mmol/l is accepted as the definition.

ACTIONS

• As above

Key Learning Points

Most common paediatric illnesses can be assessed and treated using an ABCDE approach.

References

EPALS Manual 5th Edition

Resuscitation Council UK

www.nhs.uk/conditions

Anaphylaxis

Signs and Symptoms of an allergic reaction

Allergy and Anaphylaxis Australia allergyfacts.org.au

Recognising and Treating Acute Anaphylaxis Ausmed.co.uk/learn/articles/anaphylaxis

anaphylaxis.org.uk

Anaphylaxis definition, overview and clinical support tool: 2024 consensus report Journal of Allergy and Clinical Immunology 2025

Anaphylaxis in Children

South Australia Paediatric Clinical Practice Guidelines

Acute Management of Anaphylaxis https://www.allergy.org.au/hp/papers/acute-management-of-anaphylaxis-guidelines

https://www.allergy.org.au/health-professionals/papers

Asthma

Asthma.org.au

Seizures

Seizures in Children

South Australia Paediatric Clinical Practice Guidelines

Sepsis

Bacterial Sepsis

Benjamin Bullock; Michael D Benham

Stat Pearls ncbi.nlm.nih.gov

Australiansepsisnetwork.net.au

Pathophysiology of sepsis

Am J Health Syst Pharm 202 Feb 15:59Suppl1:S3-8Judith Jacobi

Epidemiology of Sepsis in Australian Public Hospitals

Australian Commission on Safety and Quality in Healthcare Feb 2020 safetyandquality.gov.au

Images of meningococcal rash ausmed.co.uk

Hypoglycaemia

Clinical Practice Guidelines

The Royal Children’s Hospital Melbourne NICE

BNFC

Hypoglycaemia in the ED Niamh Conlon Dontforgetthebubbles.com

Age

Less than 6 month

6 months -

6 Years

Adrenaline 1:1000 !!!Intramuscular route only!!!

100-150 micrograms (0,1ml - 0.15ml)

150 micrograms (0.15ml)

6 Years – 12 years 300 micrograms (0.3ml)

Older than 12 years (adult dosage)

500 Micrograms (0.5ml)

Anaphylaxis Algorithm

Patient with of one or more of the following:

• Itchy Rash (urticaria)

• Swelling to lips, tongue or throat

• Wheeze

Consider Allergic Reaction

!REMOVE ALLERGEN IF POSSIBLE!

Assess patient

Airway

Breathing

Circulation

Disability

Exposure

CONSIDER ANAPHYLAXIS

If all 3 criteria met

• Unexpected and sudden onset

• Clinical signs (life threating)

o Rapid breathing

o Evidence of poor circulation

o Stridor, Hoarseness or Wheeze

o Tongue Swelling Pale, Clammy, Rash, flushed, skin changes

NO

Reference:

Van de

P. et al (2021)

European Resuscitation Council Guidelines 2021: Paediatric Life Support , Vol 161, pg 327 -387

Mild Allergic Reaction?

• Perform observations (Respirations, oxygen saturations Pulse,)

• Frequent observations for 90 minutes

• Antihistamine orally as prescribed

YES

NO IMPROVEMENT OR PATIENT DETERIORATES

Seek assistance – request emergency team if available or activate 999 system

• M onitor –Perform Resps and Oxygen Saturation Pulse,and BP (if available)

• O xygen – provide high flow supplemental oxygen (15 litres per minute through non-rebreathe mask, if available)

• V enous access – If trained to do so establish intravenous or intraosseous access

• E PINEPHRINE (Adrenaline) USE 1:1000 SOLUTION STRENGTH

• If profound shock immediately life threatening start CPR as appropriate

• Absolute accuracy of small dosage not essential

• IV fluids infused rapidly (must be prescribed) 10ml/kg crystalloid (only of equipment & skills available)

Repeat Adrenaline (1:1000) IM after 5 minutes if no improvement If no improvement after two doses of adrenaline, confirm that help is on the way

• Follow local protocol for transfer of the unwell child

• Clinical staff MUST NOT leave the patient until ambulance service/retrieval team arrive

• Continuous observations –respiratory rate and oxygen saturations, Pulse, BP (if available)

Voorde

Mild hypoglycaemia?

Hypoglycaemia Algorithm

Patient diabetic or at risk of hypoglycaemia and showing one or more of the following:

• Sweating

• Tremor

• Impaired consciousness

• Combative or aggressive

• Coma

• Convulsions

Assess patient

Airway

Breathing

Circulation

Disability

Check beside blood glucose

Exposure

• Give oral glucose or glucose or sugary drink

• Give carbohydrate (bread or biscuit or crisps)

• Perform observations (Pulse, Respirations, oxygen saturations)

• Give oxygen

• Frequent observations for 90 minutes

REGAINS CONSCIOUSESS?

blood glucose < 4

Patient conscious?

• Repeat blood glucose half hourly NO

NO IMPROVEMENT OR PATIENT DETERIORATES YES

IM Glucagon 1mg aged 8 and above.

0.5mg under 8

Any impaired consciousness?

• Perform observations (Respirations, oxygen saturations BP, Pulse (if possible))

• Give oxygen

• Frequent observations for 90 minutes NO

NO IMPROVEMENT OR PATIENT DETERIORATES

Seek assistance – request emergency team if available or activate 999 system

• M onitor –Perform Resps and Oxygen Saturation Pulse,and BP (if available)

• O xygen – provide high flow supplemental oxygen (15 litres per minute through non-rebreathe mask, if available)

• V enous access – If trained to do so establish intravenous or intraosseous access

• E mergency airway manoeuvers – head tilt chin lift, oral pharyngeal or nasal airway, LMA/i-Gel as appropriate

MUST DO FOLLOWING ACTIONS

• Follow local protocol for transfer of the unwell child

• Clinical staff MUST NOT leave the patient until ambulance service/retrieval team arrive

• Continuous observations – Pulse, B/P, respiratory rate and oxygen saturations and neurological observations

Hypovolaemic & Distributive Shock Algorithm

Evidence of bleeding and/or fluid loss/maldistribution and patient showing one or more of the following:

• Tachycardia (usually associated with poor volume and peripheral pulses)

• Poor peripheral perfusion

• Delayed capillary refill

• Altered mental status

• Low blood pressure

• Poor urine output

• Dry mucous membranes

Assess patient Airway Breathing

Circulation

Disability

Check bedside blood glucose

Exposure

Obtain IV/IO access or check patency

Administer 10mls/kg of crystalloid (0.9% saline) YES

Reference:

Van de Voorde P. et al (2021) European Resuscitation Council Guidelines 2021: Paediatric Life Support , Vol 161, pg 327 -387 Resuscitation Council UK (2021) European Paediatric Advanced Life Support th

Reassess ABCDE Improvement?

• Perform observations (Respirations, oxygen saturations, BP, pulse, peripheral perfusion (if possible))

• Give oxygen

• Frequent observations for at least 90 minutes

NO

PATIENT DETERIORATES

Seek assistance – request emergency team if available or activate 999 system

• M onitor –Perform Resps and Oxygen Saturation Pulse,and BP (if available), stop bleeding if apparent

• O xygen – provide high flow supplemental oxygen (15 litres per minute through non-rebreathe mask, if available)

• V enous access – obtain second vascular access site, attempt vascular access if only IO in situ

• E mergency management – further bolus administration of 10ml/kg crystalloids.

MUST DO FOLLOWING ACTIONS

• Follow local protocol for transfer of the unwell child

• Clinical staff MUST NOT leave the patient until ambulance service/retrieval team arrive

• Continuous observations –respiratory rate and oxygen saturations Pulse, BP, and neurological observations

Suspected Meningitis Algorithm

Patient showing one or more of the following clinical signs of meningitis:

Age 0 – 3 – Bulging fontanelle (up to 18 months), unexplained drowsiness. high pitched cry or irritability not easily soothed, pyrexia

Over 3 – headache, photophobia, vomiting, neck rigidity, pyrexia

All ages – non-blanching purpuric rash, sepsis, evidence of raised intracranial pressure (rash may be atypical or absent)

Reassess

NO

Assess patient

Airway

Breathing

Circulation

Disability

Check bedside blood glucose

Exposure

Seek assistance – request emergency team if available or activate 999 system

Reassess

Signs of early compensated shock?

• M onitor –Perform Resps and Oxygen Saturation Pulse,and BP (if available)

• O xygen – provide high flow supplemental oxygen (15 litres per minute through non-rebreathe mask, if available)

• V enous access – If trained to do so establish intravenous or intraosseous access

• E xpert help and emergency drugs – contact paediatrician/anaesthetist, give IV Ceftriaxone 80mg/kg

Volume resuscitation –10ml/kg crystalloid

Satisfactory Response

If there are still signs of shock after 40-60ml/kg fluid resuscitation – will require elective intubation and ventilation

Reference:

Van de Voorde P. et al (2021) European

Resuscitation Council Guidelines 2021:

Paediatric Life Support , Vol 161, pg 327 -387

Resuscitation Council UK (2021) European

Paediatric Advanced Life Support Manual 5th Edition, Pg 137 – 162

MUST DO FOLLOWING ACTIONS

• Follow local protocol for transfer of the unwell child

• Clinical staff MUST NOT leave the patient until ambulance service/retrieval team arrive

• Continuous observations –respiratory rate and oxygen saturations, Pulse, BP,

This guidance/algorithm is intended to supplement local Trust guidance and should only be utilised for immediate initial management in the event of a medical emergency situation

Signs of raised intracranial pressure?

Seizure Algorithm

• Patient with of one or more of the following:

• Generalised fit/convulsion

• Repeated small fits or patient post ictal

• Localised seizure activity patient post ictal

Assess patient Airway Breathing Circulation Disability

Check bedside blood glucose Exposure

Go to Hypoglycaemia Algorithm YES

blood glucose < 3 NO

Seek assistance – request emergency team if available or activate 999 system

• M onitor –Perform Resps and Oxygen Saturation Pulse,and BP (if available)

• O xygen – provide high flow supplemental oxygen (15 litres per minute through non-rebreathe mask, if available)

• V enous access – If trained to do so establish intravenous or introsseous access

• E nsure that environment is safe for patient – pillows, cotsides, suction available

Normal seizure activity?

• Perform observations (Respirations, oxygen saturations BP, Pulse (if possible))

• Give oxygen

• Frequent observation for 60 minutes

• Neurological observations

NO IMPROVEMENT OR PATIENT DETERIORATES

Reference:

NICE (2021) Treating prolonged or repeated seizures and status epilepticus https://pathways.nice.org. uk/pathways/epilepsy

Resuscitation Council UK (2021) European Paediatric Advanced Life Support Manual 5th Edition, Pg 137 - 162

Seizure self-terminating and lasting < 2 minutes and patient known epileptic

Give buccal midazolam 0.30.5mg /kg (as prescribed) or Ensure effective airway management NO

MUST DO FOLLOWING ACTIONS

• Follow local protocol for transfer of the unwell child

• Clinical staff MUST NOT leave the patient until ambulance service/retrieval team arrive

• Continuous observations –, respiratory rate, oxygen saturations and Pulse, BP and neurological observations

10 MINUTES AND PATIENT STILL FITTING REASSESS PATIENT

REPEAT MIDAZOLAM OR LORAZEPAM

12. Post Resuscitation Care

Learning Outcomes

To understand:

• The importance of an ABCDE approach for post-resuscitation stabilisation and optimisation of organ function following cardiorespiratory arrest.

• The specific investigations and monitoring indicated.

• How to facilitate safe transfer of the seriously ill child.

Post-resuscitation care begins with the return of spontaneous circulation (ROSC) with the aim of achieving haemodynamic stability to preserve cerebral function and to prevent secondary organ damage.

The ABCDE approach can be used to focus management. Following ROSC many specialty teams may need to be involved particularly if the child needs to be transferred to a different hospital. One member of the team should liaise with paediatric intensive care to find a suitable bed for the patient and to ask advice regarding further management. The rest of the team should use the ABCDE approach to reassess and manage the patient further.

Continued assessment and Resuscitation

Airway and Breathing

The aim here is to maintain adequate ventilation and oxygenation avoiding hypoxia and hypo/hypercapnia. Continuous monitoring of SpO2 is mandatory. Hyperoxia should also be avoided and oxygen delivery titrated according to saturations to maintain SpO2 between 94-98%.

Blood gases (capillary or arterial) should be checked regularly.

Considerations are:

• Definitive airway with placement of ETT

• Nasogastric tube insertion

Definitive airway with placement of ETT

If the child has been resuscitated using BVM and is still unconscious or requiring respiratory support, they will require intubation. An anaesthetist may be required for intubation. If the child starts to make respiratory effort whilst intubated, they will need sedation and analgesia until transferred End-tidal CO2 monitoring will be required if the child is intubated.

Endotracheal intubation is accompanied by potential complications which can be remembered by the mnemonic DOPES as shown below:

D Displacement of tube into oesophagus or right main bronchus

O Obstruction with secretions or by kinking of the tubing

P Pneumothorax which may have been caused by excessive airway pressure

E Equipment failure

S Stomach distension

Nasogastric tube insertion

Following BVM ventilation the stomach becomes filled with air which can impair ventilation and make the child more likely to regurgitate stomach contents. Insertion of a nasogastric tube (NGT) with aspiration of stomach contents is required to prevent this.

A chest x-ray will be required to check the position of the EET (above carina, T2-3), NGT and also to look for underlying lung pathology

Circulation

The aim here is to maintain adequate organ perfusion. The heart rate should be monitored continuously using ECG or SpO2. Regular blood pressure monitoring will be required. End-organ perfusion should be assessed using skin temperature or CRT and by measuring urine output.

Considerations are:

• Intravenous access

• Blood sampling

• Inotropes

• Measuring urine output

Intravenous access

If an intraosseous line has been used during resuscitation insertion of an intravenous line should be attempted. Central venous access may be required but needs specialised skills and experience.

Blood sampling

Blood samples should be sent to the laboratory for formal analysis of electrolytes, haemoglobin etc. Specific replacement of electrolytes, haemoglobin or clotting factors may be required depending on the results

Inotropes

Further fluid boluses of isotonic fluid may be required. If 30-40ml/kg has been administered inotropes will be required. These need to be administered as a continuous infusion. Adrenaline is the first-line inotrope and can be given peripherally in a well diluted solution if central access is not available.

Measuring urine output

Urine output should be measured and recorded. This may require insertion of a catheter. In babies and children who still require nappies the weight of the nappy can be used to measure urine output.

Disability

The main cause of death after ROSC is brain injury. The brain is vulnerable to ischaemia and hypoxia which may occur as a primary injury or as a secondary injury after ROSC. The aim of postresuscitation care is to prevent secondary brain injury. An assessment of neurological status should be performed early-on to obtain a post-resuscitation baseline and level of consciousness monitored. AVPU or Glasgow coma scale along with pupillary responses and any abnormal posturing should be recorded. If the child is sedated, accurate assessment will be difficult.

Considerations are:

• Stabilising blood pressure

• Analgesia and sedation

• Treating seizures

• Normalising blood gases

• Correcting electrolyte disturbances

• Maintaining blood glucose

• Stabilising blood pressure

Stabilising blood pressure is important to maintain cerebral perfusion which is dependent on mean arterial blood pressure (Cerebral Perfusion Pressure = Mean Arterial Pressure –Intracranial Pressure). Mean blood pressure should be maintained at or slightly above the child’s normal level using fluid boluses or inotropes as required.

• Analgesia and sedation

Children who are unconscious after ROSC and require on-going ventilation with intubation will need adequate analgesia and sedation. Neuromuscular blockade may also be required. PICU staff will be able to give advice on recommended medications. Sedation makes assessment of neurological status difficult.

• Treating seizures

Treat seizures rapidly if they occur with benzodiazepines, or Levetriacetam according to the status epilepticus algorithm; this is important as seizures increase the metabolic requirements of the brain. If the child is intubated and sedated particularly if neuromuscular blockers have been used seizures may be difficult to detect. Remember to check blood glucose level in children who develop seizures.

• Normalising blood gases

Cerebral blood flow is affected by carbon dioxide blood levels (PaCO2), both hypercapnia and hypocapnia can be detrimental. When carbon dioxide levels are too high as in hypercapnia cerebral blood vessels dilate which can increase intracranial pressure, hypocapnia causes the opposite and may restrict cerebral blood flow causing ischaemia. Aim for a normal carbon dioxide blood level (PaO2 4.5-6.0) end-tidal CO2 monitoring will help guide this. Hypoxia is detrimental to cerebral perfusion and hyperoxia may cause oxygen toxicity. Aim for SpO2 94-98% (i.e. normal PaO2 10-13 KPa) and titrate inspired oxygen accordingly. Blood gases can be assessed intermittently using arterial or capillary blood samples.

• Correcting electrolyte disturbances

Maintenance fluids at 2/3 requirement should be started using a balanced or unbalanced isotonic crystalloid solution or 0.9% saline with dextrose. Any electrolyte imbalances should be corrected.

• Monitoring for and treating intra-cranial pressure

Signs of raised intra-cranial pressure (ICP) should be reviewed and investigated. Raised ICP causes Cushing’s Triad of bradycardia, hypertension and irregular breathing. It can be treated specifically with hypertonic saline (3%) or Mannitol.

• Maintaining blood glucose

Hypoglycaemia (<3mmol/l) and hyperglycaemia are both associated with worse outcomes after ROSC. Tight control of blood glucose, however, may increase the risk of hypoglycaemia and so is not recommended. Glucose can be delivered continuously in maintenance fluids. Blood glucose should be measured regularly in unconscious or sedated patients.

Exposure

If not already undertaken a full examination should be undertaken looking for rashes, bruising etc. which may have been missed earlier.

Care should be taken to maintain the child’s body temperature within the normal range, hyperthermia/fever should be avoided and actively treated with passive cooling or anti-pyretics (IV paracetamol). If hypothermic the child should be gently rewarmed with blankets, if their temperature is less than 34⁰ active rewarming with hot air (Bair Hugger) or warmed intravenous fluids should be considered.

Facilitating Safe Transfer

Following stabilisation, the child needs to be transferred to PICU for further care. This may be within the same hospital or may involve transfer to another facility.

Considerations are:

• Method of transport

• Equipment

• Medication and oxygen for transfer

• Airway and breathing

• Circulation

• Documentation

• Information sharing

• Method of transport

Depending on where the child is to be transferred to, the mode of transport needs to be carefully considered. The safest and quickest transport system that is available should be used which may mean using land transfer by ambulance, or air transfer by helicopter, or fixed wing airplane.

• Equipment

Prior to transfer all equipment required should be assembled and checked. A checklist will help with this.

• Medication and oxygen for transfer

Emergency medication should be available for transfer in addition to medication in current use. There should be adequate oxygen for the journey with extra in case of delays in transfer.

• Airway and breathing

The airway should be secured with the endotracheal tube taped into position. The position should be checked clinically and by X-ray. Just prior to departure the ETT should be aspirated to clear secretions and the stomach deflated by aspirating the nasogastric tube.

• Circulation

Intravenous access should be secured and patency checked. Infusion fluids and medication should be transferred onto syringe drivers or other portable devices. Extra fluids and medication may be required, depending on how long transfer is likely to take.

• Documentation

Copies of hospital notes including resuscitation documentation, X-rays and laboratory results should be available.

• Information sharing

Contact PICU to update on current status and give an estimated time of departure

Inform parents/caregivers of transfer details and ensure they have appropriate means of transport to PICU

Monitoring:

The following may be required:

• ECG

• Pulse oximeter (SpO2)

• Blood pressure (non-invasive or invasive)

• End-tidal CO2

• Respiratory rate

• Central venous pressure

Following ROSC, the child’s physiological parameters are likely to be deranged, and the following investigations may be required:

Investigation

ABG/CBG including lactate

Biochemistry

FBC

Clotting

Group & save

Blood Culture

CXR

Urine

12-lead ECG

Key Learning Points

Rationale

Adequacy of ventilation

Assessment of tissue perfusion

UEC

LFT

Mg, Ca

Blood glucose

Infection markers CRP, procalcitonin, ferritin etc.

Hb, WCC, Plt. O2 carrying capacity, sepsis, caogulopathy

Coagulopathy from sepsis of hypoxia

Crossmatch if anaemia and transfusion required

If sepsis suspected

Position ETT and NGT

Underlying lung pathology

Pneumothorax

Rib fractures

Toxicology

Culture

Renal function

Cardiac damage

Arrhythmia detection

• ROSC is the first step in continuous resuscitation management and the prognosis for children following cardiorespiratory arrest depends on the quality of post-ROSC care.

• Ongoing management after ROSC includes appropriate monitoring and supportive treatment based on an ABCDE approach.

References

European Paediatric Advanced Life Support 5th Edition

Resuscitation Council UK

Paediatric Immediate Life Support 2nd Edition

Resuscitation Council UK

13. Human Factors and Non-technical skills in resuscitation

Learning Outcomes

To understand:

• The role of human factors in resuscitation

• The roles of team leader and team member

• The importance of structured communication in handover

Effective resuscitation requires a number of technical skills such as airway management, chest compressions, vascular access etc. however a good resuscitation team also needs its members to have effective non-technical skills. Non-technical skills (NTS) are defined as “as a constellation of cognitive, social and personal skills, exhibited by individuals and teams, needed to reduce error and improve human performance in complex systems”. Good non-technical skills really make a difference in resuscitation teams.

The importance of non-technical skills became apparent following various disasters in the aviation industry in the 1970s. As technology improved the human contribution to accidents became more apparent such as, poor communication between pilots and air traffic control leading to accidents. The aviation industry developed Cockpit Resource Management (CRM) training for pilots which improved safety. This was expanded to all flight crew as Crew Resource Management and since then the nuclear power industry and healthcare have introduced non-technical skill training and assessment to improve safety.

There are several categories of non-technical skills:

• Situational awareness

• Decision making

• Team working and Leadership

• Task Management

• Communication

Situational awareness

This describes an individual’s awareness of the environment at the moment of an event and the awareness of how an individual’s actions may impact on future events. This becomes important when there are many events happening simultaneously such as at a cardiac arrest. Situational awareness involves information gathering about the cause of the cardiac arrest, interpretation of the situation and planning interventions. Poor situational awareness can lead to poor decision making. In a well-functioning team, all members have a common understanding of current events.

Decision making

This is defined as choosing a specific course of action from several alternatives. In a cardiorespiratory arrest team decision making falls to the team leader, who is usually a senior experienced nurse or doctor, however, some decisions are taken by first responders until the rest of the team arrives. These decisions include confirmation of cardiorespiratory arrest and calling the resuscitation team, starting CPR etc. The team leader will have to make further decisions such as considering and ruling out likely reversible causes of the arrest, appropriate treatment including management of the airway, administration of drugs or defibrillation etc. The team leader also ultimately decides when to stop the resuscitation, although the views of all team members is asked. Once a decision has been made it is essential that clear unambiguous communication is used to ensure that the decision is implemented.

Team working and Leadership

A team is a group of individual working together with a common goal or purpose. Team members usually have complimentary skills and work synergistically. Team leadership can be taught, observed and practised. Team membership can be improved by rehearsal including simulation training, and with reflection through debriefing and coaching. Teams work best when everyone knows each other’s name and they are doing something they perceive to be important.

A team meeting or “huddle” at the beginning of a shift with all team members ensures that the team know each other and their competencies. It allows for the identification of the team leader and allocation of tasks if a cardiorespiratory arrest should occur. Often huddles are also used to identify seriously ill children.

Team Leadership

All resuscitation teams require a team leader who provides guidance, direction and instruction to the team. The team leader should be easily identifiable to the team and requires experience not just seniority. The team leader should remain “hands-off” to have a global perspective of the resuscitation.

An ideal team leader:

• Accepts the role and is experienced and knowledgeable

• Knows everyone in the team by name

• Knows the competencies of the team members

• Delegates tasks appropriately preferably before the event

• Stays calm, and keeps the team focused

• Is assertive

• Is empathetic towards the whole team

• Is a good communicator

• Has good situational awareness

The team leader is responsible for thanking the team and ensuring that all documentation is completed.

Team Members

The traditional “cardiac arrest team” is made up of several individuals from various specialties including nursing, medical, surgical, anaesthetic, and intensivists depending on the facilities within the hospital. The members of the team will change with each shift change and may not know each other. If possible, at the beginning of each shift a team meet, or “huddle” should take place. Name tags should be used, and role stickers can also help.

Resuscitation team members should be:

• Competent in the skill allocated to them

• Committed to achieve the best for the patient

• Following the same algorithm

• Able to communicate openly with the leader and other team members their findings and actions taken

• Supportive and prepared to help, looking out for fatigue in team members e.g. physical fatigue from compressions

• Accountable for their actions

• Able to feedback

Task Management

During a resuscitation there are numerous tasks that need to be performed sequentially or simultaneously.

The following roles are needed:

• Team leader

• Airway management

• Monitor application

• Identifying rhythm and delivering safe defibrillation

• Intravenous access

• Medications

• Chest compressions

• Scribe/record keeper

• Support of parents/caregivers

Some of these tasks may be undertaken by the same individual i.e. vascular access and drugs

Cognitive aids such a copy of algorithms, emergency drug charts or checklists should be used to support team members and guide decision making.

Communication

Communication problems are a factor in up to 80% of adverse events or near-misses. Failure to communicate the seriousness of the situation heightens the anxiety of the responder who may be uncertain of the nature of the problem. Structured handover tools have been devised which can help ensure that the important information is conveyed in such a way that the recipient is clear about what is required of them. SBAR (Situation, Background, Assessment, Recommendation) and RSVP (Reason, Story, Vital signs, Plan) are tools that can be used to improve handover of information.

SBAR RSVP Content Example

Situation Reason Introduce yourself and ensure that you are talking to the right person.

Identify the patient

Hi, I’m Dr Smith I’m calling about Ellie Jones on ward 4. She has pneumonia and is septic. Her oxygen saturations have

Background Story

Assessment Vitals

Recommendation Plan

Decision -----

State current problem and what you need advice about dropped and are now 92% on high flow oxygen

Background information including reason for admission

Relevant past medical history

ABCDE assessment PEWS score

She is 3-yr old and has no pre-existing conditions

She has been unwell for 2-days with fever and cough and is on oral antibiotics

She is responding to voice but is listless

She is talking but breathless

Her respiratory rate is 36, and oxygen saturations 92%.

Her pulse is 159 and her BP 90/60

She is drowsy

Her temperature is 39.4⁰

Her CEWT score is 6

State explicitly what you want the person to do

State when you want the person to do it

What has been agreed between the referring clinician and the receiving clinician

This should include initial treatment and timeframe for attendance

Debrief and Audit

I’m going to insert an intravenous cannula

Please can you come straight away and prescribe fluids and intravenous antibiotics

Thank you, please give xxx fluids and repeat observations every 5 minutes, contact me if any further deterioration. I will attend in the net 10 minutes

After any resuscitation attempt the team members should be given the opportunity to meet for debrief and submit incident reports. During the debrief difficulties or concerns about performance, equipment etc can be discussed and feedback given. Debriefing has been shown to enhance team performance.

Key Learning Points

• Non-technical skills are important during resuscitation

• Handover tools (SBAR or RSVP) are useful for effective communication

References

European Paediatric Advanced Life Support 5th Edition

Resuscitation Council UK

Paediatric Immediate Life Support 2nd Edition

Resuscitation Council UK

Non- technical skills in cardiac arrests: a brief practical summary The Anaesthesia Collective https://www.anaestheticcollective .com

Effectiveness of nontechnical skills educational interventions in the context of emergencies: A systematic review and meta-analysis

María Sánchez-Marco, MSc ∙ Silvia Escribano, PhD ∙ María Rubio-Aparicio, PhD∙Rocío JuliáSanchis, PhDa María-José Cabañero-Martínez, PhD

Australian Critical Care Vol 36, Issue 6, P1159-1171 November 2023

Non-technical skills in Healthcare Textbook of Patient Safety and Clinical Risk Management [Internet] ncbi.nlm.nih.gov/books

14. Treatment Escalation Planning and Do Not Attempt Resuscitation Orders

Learning Outcomes

To understand:

• The concept of medical ethics

• When CPR should not be attempted (DNACPR)

• When to stop CPR

Medical Ethics

Medical ethics is the study of the moral principles which guide the behaviour of healthcare professionals. These ethics ensure that the patient’s well-being is prioritized, and that patients are treated with respect and dignity, thus fostering trust and confidence in the healthcare system.

Ethical principles are not static but have changed and will continue to change over time varying with cultural and social practices prevalent at the time.

There are four pillars or principles of medical ethics which are:

• Autonomy

Autonomy is respecting the right for people to make their own decisions. To make their own medical decision patients must have competence or mental capacity to make decisions about their healthcare. They must be free to make the decision and not be under duress or undue pressure. They must be well informed about available options particularly about the risks and benefits of any proposed treatment. Autonomy allows the person to make the choice even if that choice seems illogical or incorrect by others including parents/guardians and healthcare professionals.

Young children or those with learning disabilities lack competence/capacity and parents/guardians make decisions for them.

As children grow and mature, they will generally gain competence and are able to consent to their own treatment themselves. People over 16 are entitled to consent to their own treatment. Children under 16 who are Gillick competent are able to give consent to their treatment; they may also refuse life-saving treatment, but this decision can be over-ruled by guardians/parents.

• Beneficence

All medical acts must be for the best interests of the patient.

• Non-maleficence

The actions of the healthcare professional should not be harmful to the patient.

• Justice

There should be no discrimination on grounds of age, race, sex, religion, socioeconomics, or disability.

Ethics of Paediatric CPR

Cardiorespiratory arrest in children is rare and unpredictable. It usually occurs in children who are previously well but have suffered severe trauma or have a severe acute illness. There is little time to discuss treatment options before the event and consent for life-saving treatment is presumed and medical professionals have a duty of care to start resuscitation.

Do Not Attempt Cardiopulmonary Resuscitation (DNACPR)

Some children and young people have illnesses that are irreversible, and death is inevitable. For these patients CPR is unlikely to work, and it is futile to start CPR as it will cause more suffering and prolong the process of dying. In such patients it is preferable to make advanced plans regarding realistic and appropriate treatments. Decisions regarding resuscitation should be discussed between the parents/guardians, the healthcare professionals and the patient if possible. Open and honest communication between parents/guardians and healthcare professional is crucial for making informed and appropriate decisions. The decisions which involve not initiating CPR or other resuscitative efforts should be documented in the patient’s medical records. The focus should be on ensuring comfort and relief from distress.

It is important to note that DNACPR does NOT mean stopping or with-holding all treatment, only some life-saving treatments may be stopped whist others continue e.g. continue treatment with antibiotics, nasogastric feeding etc. The palliative care team may become involved.

Parents/guardians are able to change their mind regarding DNACPR decisions if they have doubts about their decision or second thoughts. This will require further discussions with healthcare professionals and documentation in the patients notes of the new decision.

The specific legal framework for DNACPR decisions varies by state and territory in Australia but ethical considerations focusing on the best interests of the child apply to all.

When to stop CPR

Not all attempts at CPR are successful and resuscitation should be terminated when:

• The rescuer is too exhausted to continue

• The rescuer is in danger

• In children when CPR has been continued for at least 30-minutes without return of spontaneous circulation except in cases of hypothermia, poisoning, persistent VF/pVT

• In newborn babies who fail to respond to resuscitation efforts within 20-minutes

Key Learning Points

• Medical ethics guide the morals of medical treatment.

• The four guiding principles of medical ethics are autonomy, beneficence, mon-maleficence and justice.

• Children with conditions that are likely to lead to natural death and in whom resuscitation is inappropriate can have DNACPR order which should be documented in their medical records.

References

Caring Decisions: Different types of Treatment

Clinical Practice Guidelines

www.rch.org.au

Legal and Ethical Issues Related to Resuscitation

Section 10: Guideline 10.5

ANZCOR Guidelines www.anzcor.org

EPALS Manual 5th Edition

Resuscitation Council UK