1. PALS AND OEMS DAN MUSE MD
PEDIATRIC CARDIOLOGY
PALS AND OEMS
DAN MUSE MD

2. PEDIATRIC ASSESSMENT PRIMARY ASSESSMENT Rapid assessment: Respiratory
Cardiac
Neurologic

3. PEDIATRIC ASSESSMENT PRIMARY ASSESSMENT Airway Breathing Circulation
AVPU: Alert, Voice, Pain, Unresponsive

4. CARDIOPULMONARY ASSESSMENT
PEDIATRIC ASSESSMENT
CARDIOPULMONARY ASSESSMENT
In infants and children cardiopulmonary collapse is due primarily to:
Respiratory failure
Shock

5. CARDIOPULMONARY ASSESSMENT
PEDIATRIC ASSESSMENT
CARDIOPULMONARY ASSESSMENT
As the kids grow up cardiac issues may present
They are predominantly arrhythmias.
Ischemia is not one of them!

6. CARDIOPULMONARY ASSESSMENT
PEDIATRIC ASSESSMENT
CARDIOPULMONARY ASSESSMENT
Congenital
Tetrology of Fallot
Brugada’s Syndrome
Prolonged QT

7. CARDIOPULMONARY ASSESSMENT
PEDIATRIC ASSESSMENT
CARDIOPULMONARY ASSESSMENT
Developmental
WPW/Svt’s
Idiopathic Hypertrophic Cardiomyopathy
Cardiomyopathy

8. CARDIOPULMONARY ASSESSMENT
PEDIATRIC ASSESSMENT
CARDIOPULMONARY ASSESSMENT
Accidental
Commodio Cordis
Drugs

9. PEDIATRIC ASSESSMENT CARDIAC ARRHYTHMIAS Defined as Bradyarrhythmias
Tachyarrhythmias
Pulseless arrest

10. BRADYARRHYTHMIAS Defined as
Slow heart rate based on normal rate for age.
Primary Bradycardia: Due to congenital or acquired heart conditions.
Secondary Bradycardia: Due to underlying conditions such as hypoxia, sepsis, acidosis, hypotension, drugs…

11. BRADYARRHYTHMIAS
BRADYARRHYTHMIAS ARE FREQUENTLY PREARREST RHYTHMNS IN CHILDREN AND OFTENTIMES DUE TO HYPOXIA

12. BRADYARRHYTHMIAS OEMS PROTOCOLS
EMT/EMT-INTERMEDIATE/ADVANCED EMT STANDING ORDERS
Routine Patient Care
If pulse is less than 60 in a child, AND the patient is severely symptomatic, consider starting Cardiopulmonary Resuscitation (CPR).

13. BRADYARRHYTHMIAS OEMS PROTOCOLS
PARAMEDIC STANDING ORDERS
IF PATIENT IS SEVERELY SYMPTOMATIC:
Epinephrine 1:10,000, 0.01 mg/kg IV/IO (max. dose 0.5 mg) OR,
Atropine 0.02 mg/kg IV/IO (min. single dose 0.1 mg, max. single dose 1 mg). If increased vagal tone or AV block suspected.

14. BRADYARRHYTHMIAS OEMS PROTOCOLS
MEDICAL CONTROL MAY ORDER
Additional doses of above medications
Additional fluid boluses (10-20mL/kg)
Transcutaneous pacing, if available.

15. BRADYARRHYTHMIAS OEMS PROTOCOLS
MEDICAL CONTROL MAY ORDER
Epinephrine 1:10,000 – mg/kg IV/IO (max. single dose of 0.5 mg)
Epinephrine Infusion 1:1,000, mcg/kg/min IV/IO. For example, mix 1mg of Epinephrine 1:1000 in 250mL of Normal Saline, (15 micro drops/minute = 1 mcg / min.)
Treat other conditions according to specific protocols.

16. TACHYARRHYTHMIAS
Abnormally rapid rates that originate in the atria or the ventricles
Certain arrhythmias such as SVT’s and Ventricular Tachycardia can lead to shock and death.

17. TACHYARRHYTHMIAS Heart rate : Infants greater than 220
SVT
Heart rate :
Infants greater than 220
Children greater than 180
P waves are abnormal or hidden: NOT SINUS
PR interval may be absent or short
R-R interval is constant
Complex's are usually narrow.
SVT with aberrancy

18. TACHYARRHYTHMIAS OEMS PROTOCOLS
EMT/EMT-INTERMEDIATE/ADVANCED EMT STANDING ORDERS
Routine Patient Care
If tachycardia is related to acute injury or volume loss, see 2.16P Shock.

19. TACHYARRHYTHMIAS OEMS PROTOCOLS
PARAMEDIC STANDING ORDERS
IV Normal Saline (KVO). If hypovolemic component is suspected, administer 20 mL/kg IV Bolus of Normal Saline.

20. TACHYARRHYTHMIAS OEMS PROTOCOLS
MEDICAL CONTROL MAY ORDER
Additional doses of above medications
Synchronized cardioversion 0.5 joules/kg for symptomatic patients.* Subsequent cardioversion may be done at up to 1 joule/kg. If cardioversion is warranted, consider administration of 7.6 Sedation for Electrical Therapy, per protocol.
See A2 Pediatric Color Coded Medication Reference for dosing.
Adenosine 0.1 mg/kg rapid IV/IO. If no effect, repeat Adenosine 0.2 mg/kg Rapid IV push. MAXIMUM single dose of Adenosine must not exceed 12 mg.
 Consider Vagal maneuvers (see Reminder below).
Treat other conditions according to specific protocols

21. TACHYARRHYTHMIAS OEMS PROTOCOLS
OEMS WARNING
Synchronized cardioversion should be considered for only those children whose heart rate is in excess of 220, and who demonstrate one or more of the following signs of hypoperfusion: Decreased level of consciousness, weak and thready pulses, capillary refill time of more than 4 seconds, or no palpable BLOOD PRESSURE.

22. TACHYARRHYTHMIAS OEMS PROTOCOLS
OEMS WARNING
REMINDER: Vagal maneuvers may precipitate asystole and therefore should be employed with caution in the field and only in a cardiac-monitored child with IV access.

23. VENTRICULAR TACHYCARDIA WITH PULSES
OEMS PROTOCOLS
EMT/EMT-INTERMEDIATE/ADVANCED EMT STANDING ORDERS
Routine Patient Care

24. VENTRICULAR TACHYCARDIA WITH PULSES
PARAMEDIC STANDING ORDER
Unstable pediatric patients, synchronized cardioversion per Pediatric Color-Coded Appendix.
If cardioversion is warranted, see 7.6 Sedation for Electrical Therapy
Stable pediatric patient administer Amiodarone dose per Pediatric Color-Coded Appendix

25. CARDIAC ARREST OEMS PROTOCOLS
EMT / EMT-INTERMEDIATE / ADVANCED EMT STANDING ORDERS
Routine Patient Care—with focus on high quality CPR
Apply AED and use as soon as possible (with minimum interruption of chest compressions). From birth to age 8 years use pediatric AED pads.
If pediatric AED pads are unavailable, providers may use adult AED pads, provided the pads do not overlap.

26. CARDIAC ARREST OEMS PROTOCOLS
EMT / EMT-INTERMEDIATE / ADVANCED EMT STANDING ORDERS
If unable to ventilate child after repositioning of airway, assume upper airway obstruction and follow Pediatric Upper Airway Obstruction Protocol.
Consider treatable causes

27. CARDIAC ARREST OEMS PROTOCOLS
PARAMEDIC STANDING ORDERS
Defibrillate once at 2-4J/kg.
Epinephrine: 0.01mg/kg IV/IO (1:10,000, 0.1mL/kg); repeat every 3-5 minutes.
Defibrillate 4-10 J/kg (do not exceed 10J/kg) every 2 minutes.
Amiodarone 5 mg/kg IV/IO
Defibrillate 4 J/kg seconds after each medication.

28. CARDIAC ARREST OEMS PROTOCOLS
MEDICAL CONTROL MAY ORDER
Additional doses of above medications
Sodium Bicarbonate 1 mEq/kg IV/IO.
All other treatment modalities based upon suspected cause of VT/FT.
Treat other conditions according to specific protocols.