PBLS, PALS, NLS According to European Resuscitation Council Guidelines for Resuscitation 2010 MD PhD Mariusz Mielniczuk Chair and Department of Anaesthesiology and Intensive Therapy Department of Paediatric Anaesthesiology and Intensive Therapy Collegium Medicum, Nicolaus Copernicus University in Bydgoszcz

ERC 2010

Epidemiology In children, secondary cardiopulmonary arrests, caused by either respiratory or circulatory failure, are more frequent than primary arrests caused by arrhythmias. So-called asphyxial arrests or respiratory arrests are also more commonin young adulthood (e.g., trauma, drowning, poisoning).

Signs of respiratory failure Respiratory rate outside the normal range for the child’s age – either too fast or too slow. Initially increasing work of breathing, which may progress to inadequate/decreased work of breathing as the patient tires or compensatory mechanisms fail, additional noises such as stridor, wheeze, grunting, or the loss of breath sounds. Decreased tidal volume marked by shallow breathing, decreased chest expansion or decreased air entry at auscultation. Hypoxaemia (without/with supplemental oxygen) generally identified by cyanosis but best evaluated by pulse oximetry. Level of consciousness may decrease because of poor cerebral perfusion

Signs of circulatory failure Increased heart rate (bradycardia is an ominous sign of physiological decompensation). Decreased systemic blood pressure. Decreased peripheral perfusion (prolonged capillary refill time, decreased skin temperature, pale or mottled skin). Weak or absent peripheral pulses. Decreased or increased intravascular volume. Decreased urine output and metabolic acidosis. Level of consciousness may decrease because of poor cerebral perfusion

Signs of cardiopulmonary arrest Unresponsiveness to pain (coma). Apnoea or gasping respiratory pattern. Absent circulation - without signs of life (no breathing, cough or any detectable movement) Pallor or deep cyanosis

When to start CPR Palpation of a pulse is not reliable as the sole determinant of the need for chest compressions. If cardiac arrest is suspected, and in the absence of signs of life, rescuers (lay and professional) should begin CPR unless they are certain they can feel a central pulse within 10 s (infants – brachial or femoral artery; children – carotid or femoral artery). If there is any doubt, start CPR

Airway and breathing Open the airway and ensure adequate ventilation and oxygenation. Deliver high-flow oxygen. Establish respiratory monitoring (first line – pulse oximetry/SpO2). Achieving adequate ventilation and oxygenation may require use of airway adjuncts, bag-mask ventilation (BMV), use of a laryngeal mask airway (LMA), securing a definitive airway by tracheal intubation and positive pressure ventilation. Very rarely, a surgical airway may be required.

Circulation Establish cardiac monitoring (first line – pulse oximetry/SpO2, electrocardiography/ECG and non-invasive blood pressure/NIBP). Secure intravascular access. This may be by peripheral intravenous (IV) or by intraosseous (IO) cannulation. If already in situ, a central intravenous catheter should be used. Give a fluid bolus (20 ml/kg) and/or drugs (e.g., inotropes, vasopressors, anti-arrhythmics) as required. Isotonic crystalloids are recommended as initial resuscitation fluid in infants and children with any type of shock, including septic shock. Assess and re-assess the child continuously, commencing each time with the airway before proceeding to breathing and then the circulation. During treatment, capnography, invasive monitoring of arterial blood pressure, blood gas analysis, cardiac output monitoring, echocardiography and central venous oxygen saturation (ScvO2) may be useful to guide the treatment of respiratory and/or circulatory failure.

Open airway Tilting the head and lifting the chin If you still have difficulty in opening the airway, try a jaw thrust: push the jaw forward.

Looking for normal breathing Look for chest movements Listen at the child’s nose and mouth for breath sounds Feel for air movement on your cheek If the child is breathing normally: Turn the child on his side into the recovery position

Give five initial rescue breaths Mouth-to-mouth ventilation – child. Mouth-to-mouth and nose ventilation – infant Blow steadily into the over about 1–1.5 s watching for chest rise.

Chest compressions Chest compression with one hand – child Chest compression with two hands – child For all children, compress the lower half of the sternum“Push Hard and Fast”

Chest compressions - infant Chest compression in infants - with the tips of two fingers Chest compression in infants - the encircling technique For all children, compress the lower half of the sternum“Push Hard and Fast”

Recognition of foreign body airway obstruction

Paediatric foreign body airway obstruction algorithm

Cpr for 2 min adrenaline very 3-5min

5-5-chest compr

Intraosseous access a rapid, safe, and effective route to give drugs, fluids and blood products

Intraosseous access - devices

EZ-IO BIG F.A.S.T.1