Advanced Paediatric Life Support The management of cardiac arrest DON’T FORGET TO READ THE NOTES UNDER THE SLIDES!

Cardiac Arrest Learning outcomes To review your understanding of the structured approach to cardiac arrest To review your knowledge of and fluency with the cardiac arrest protocols To understand the sequences of actions from basic to advanced skills To understand the team approach To highlight differences in newborn resuscitation

Cardiac Arrest Initial Actions Commence basic life support Support airway Deliver high flow oxygen Apply monitor and assess rhythm

Appropriate for age

Airway opening manoeuvres INFANT - Neutral, with chin lift CHILD – Sniffing, with chin lift

Either with BVM or mouth to mouth A reminder of BLS and that this lecture now takes us on to identify rhythms and treat appropriately in ALS Introduce the two algorithms for VF/VT and Asystole/PEA with references to: frequency and setting of each in paediatric practice use of defibrillator in VF/VT and not in Asystole/PEA

5 rescue breaths Give 5 rescue breaths Mouth to mouth with nose pinched for over ones Mouth to mouth and nose for under ones If the nose and mouth cannot be covered in the older infant, the rescuer may attempt to seal only the infants’ nose with his mouth (and close the lips to prevent air escape) Slow breaths –about one second Lowest pressure, so as not to inflate stomach Assess by seeing chest movement While doing the rescue breaths, note whether there is any gag/cough as part of the “signs of life” assessment Note that delaying mouth to mouth in favour of waiting for a bag valve mask may allow the child to fully arrest

Effective BLS saves lives Chest compressions therefore start if there is No signs of life No pulse Slow pulse In the absence of signs of life, chest compressions must be started unless you are certain that you can feel a pulse of more than 60 beats per minute within 10 seconds. Performing chest compressions ‘unnecessarily’ is very unlikely to be harmful Compress the lower half of the sternum at least one third of the depth of the child’s/infant’s chest. INFANTS: Two finger technique - For the single rescuer as the single handed technique allows the other hand to remain on the infant’s head to keep the correct airway position and so allow less time-wasting re-positioning. Also, the only technique recommended for lay providers. This is the technique for candidates to do in the BLS test. Encircling technique - This technique has been shown in animal experiments and anecdotally in human infants to produce better coronary perfusion/aortic pressure. To be used when there is more than one professional rescuer. To be used by candidates in scenarios where practicable 15:2 rate 100-120 per minute Push hard to a depth of at least 1/3rd

Effective BLS is essential Effective BLS is essential – attention to depth recoil and rate should be monitored by the team leader Provider fatigue should be avoided Effective BLS is essential

Airway adjuncts/intubation as expedient and appropriate Instructors to mention and show equipment in the basic airway skill station

Effective BLS is essential – attention to depth recoil and rate should be monitored by the team leader Provider fatigue should be avoided

Asystole Mention checking leads and turning up ECG gain

Pulseless Electrical Activity Pulseless Electrical Activity is an impalpable pulse in the presence of a rhythm that should produce a pulse Electro-Mechanical Dis-association is a particular type of PEA usually seen in adults with severe coronary disease and therefore not relevant to children. The two names are sometimes used interchangeably

Ventricular Fibrillation Ventricular Tachycardia

Asystole PEA algorithm

VF pVT ALGORITHM Talk through each protocol Explain the rationale for adrenaline and defib Discuss timing, planned pauses, Management of relatives Duration of resuscitation attempts

4 Hs and 4 Ts Hypoxia Hypovolaemia Hyper/hypo-kalaemia (and other metabolic causes) Hypothermia Tension pneumothorax Cardiac Tamponade Toxic substances Thromboembolism Instructor notes Ask the candidates to shout out the 4 Hs and then click to project these; then ask for the 4 Ts and then click to project these.

4 Joules/kg with manual defibrillator for all ages Defibrillation One shock: 4 Joules/kg with manual defibrillator for all ages Paediatric attenuated AED age 1-8 years AED adult shock dose age over 8 years For the infant of less than one year a manual defibrillator which can adjusted to give the correct shock is recommended. However, if an AED is the only defibrillator available, it use should be considered, preferably with paediatric attenuation pads. The order of decreasing preference for defibrillation in the under ones is as follows: Manual defibrillator AED with dose attenuator AED without dose attenuator

Team Approach Discuss the roles and what they involve – how the team may have to double up where less staff are available – see colours on diagram Discuss communication via team leader Pre allocation of roles where possible Discuss when it is expedient to use advanced airway skills

Newborn resuscitation Reproduced with kind permission Newborn resuscitation A summary of the main differences in management for newlyborn children requiring resuscitation

Newborn resuscitation Reproduced with kind permission Newborn resuscitation

Family presence during resuscitation efforts In general, family members should be offered the opportunity to be present during the resuscitation of their child If the presence of parents is impeding the progress of the resuscitation, they should sensitively be asked to leave

Advanced Paediatric Life Support The management of cardiac arrest

Cardiac Arrest Management Summary Safety, stimulate, shout Open airway and check breathing 5 initial rescue breaths Check for signs of life Chest compressions & lung inflations (15:2) Assess rhythm and follow protocol Manage the team Introduce advanced interventions when expedient