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

2. 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

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

4. Appropriate for age

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

6. 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

7. 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

8. 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 per minute
Push hard to a depth of at least 1/3rd

9. 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

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

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

12. Asystole
Mention checking leads and turning up ECG gain

13. 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

14. Ventricular Fibrillation Ventricular Tachycardia

15. Asystole PEA algorithm

16. 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

17. 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.

18. 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

19. 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

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

21. Newborn resuscitation
Reproduced with kind permission
Newborn resuscitation

22. 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

23. Advanced Paediatric Life Support
The management of cardiac arrest

24. 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