2. Resuscitation The goal of resucitation is The goal of resucitation is to maintain adequate oxygenation and perfusion. to maintain adequate oxygenation and perfusion. An sequence of events should be instituted beginning with the ABC An sequence of events should be instituted beginning with the ABC

3. Resuscitation (best survival ) Children with a respiratory arrest. Children with a respiratory arrest. a short duration of CPR. a short duration of CPR. and a pulse present at the time of apnea. and a pulse present at the time of apnea.

4. Signs and symptoms suggesting the potential need for resuscitation CNS CNS lethargy,irritability,confusion lethargy,irritability,confusion Respiratory ; apnea,grunting,nasal flaring,tachypnea, poor air movement,stridor,wheesing Respiratory ; apnea,grunting,nasal flaring,tachypnea, poor air movement,stridor,wheesing

5. Signs and symptoms suggesting the potential need for resuscitation (2) Cardiovascular; Cardiovascular; Arrhythmia,bradicardia, weak pulses,poor capillary refill, hypotention Arrhythmia,bradicardia, weak pulses,poor capillary refill, hypotention Skin and mucous; Skin and mucous; Mottling, pallor, cyanosis, diaphresis, poor turgor, dry mucouse membranes Mottling, pallor, cyanosis, diaphresis, poor turgor, dry mucouse membranes

6. Resuscitation Responsiveness: Responsiveness: Gently shake if no injury Gently shake if no injury Speak loudly Speak loudly Call out for help Call out for help Position the patient Position the patient Place supine Place supine Keep neck immobilized Keep neck immobilized

7. Resuscitation Basic life support (BLS): Basic life support (BLS): 1. A irway 2. B reathing 3. C irculation Advanced life support (ADL) Advanced life support (ADL) Airway Breathing Circulation Druge&fluid Airway Breathing Circulation Druge&fluid

8. ABC An sequence of events should be instituted beginning with the ABC : An sequence of events should be instituted beginning with the ABC : Opening Airway Opening Airway Assessing Breathing Assessing Breathing Assessing Circulation Assessing Circulation

9. Respiratory support Head tilt/chin lift or jaw thrust if the cervical spine is unstable. Head tilt/chin lift or jaw thrust if the cervical spine is unstable. Looking for the rise and fall of the chest. Looking for the rise and fall of the chest. Listening at the nose and mouth for breathing. Listening at the nose and mouth for breathing. This should be done in the less than 10 seconds This should be done in the less than 10 seconds

10. Rescue breathing in an infant

11. Head tilt- chin lift maneuver

12. Combined jaw thrust-spine stabilization maneuver

13. Rescue breathing in a child

14. Mask Smallest size face mask Smallest size face mask Large enough Resuscitation Bag Large enough Resuscitation Bag Assess for mask leak Assess for mask leak Monitor patient response Monitor patient response Sellick’s maneuver Sellick’s maneuver O2 O2

15. Sellick’s maneuver Compression of the cricoid cartilage backward cartilage backwardcompressing the esophagus against the Vertebral to prevent aspiration Of gastric contents

16. Indication for endotracheal intubation Apnea, Airway obstruction unrelieved by airway opening maneuvers. Apnea, Airway obstruction unrelieved by airway opening maneuvers. Increased work of breathing that may lead to fatigue. Increased work of breathing that may lead to fatigue. The need for PEEP The need for PEEP Poor airway protective reflexes. Poor airway protective reflexes. Sedation or the need for paralysis Sedation or the need for paralysis

17. Intubation Laryngoscopy Laryngoscopy

18. Intubation reoxygenate with 100% O2 reoxygenate with 100% O2 Gasteric tube Gasteric tube Check devices Check devices Position the patient Position the patient ETT size (mm) =16+ age in yr ETT size (mm) =16+ age in yr 4

19. Nasopharyngeal Airway Appropriate Nasopharynge al Airway Appropriate Nasopharynge al Airway Apply Phenylephrine before nasopharyngeal Airway Apply Phenylephrine before nasopharyngeal Airway Concave side facing inferiorly Concave side facing inferiorly Insert Oral airway Insert Oral airway O2 O2

20. خداوند به هر پرنده‌اي دانه‌اي مي‌دهد، ولي آن را داخل لانه‌اش نمي‌اندازد.

21. Foreign body aspiration A conscious child suspected a foreign body should be permitted to cough spontaneously until: A conscious child suspected a foreign body should be permitted to cough spontaneously until: 1. coughing is not effective 2. Respiratory distress and stridor increase 3. the child becomes unconscious

24. Foreign body aspiration Abdominal thrusts with victim Standing or sitting( conscious)

25. Foreign body aspiration

26. Neonatal resuscitation High –risk situations should be anticipated by: High –risk situations should be anticipated by:  history of the pregnancy.  history of the pregnancy.  labor and delivery.  labor and delivery.  identification of signs of fetal distress.  identification of signs of fetal distress.

27. Neonatal resuscitation 5-10%require some degree of resuscitation 5-10%require some degree of resuscitation Goals are: Goals are: 1. prevent the morbidity and mortality with hypoxic-ischemic injury. 2. Re-establish adequate spontaneous respiration and cardiac output

28. Neonatal resuscitation  IF Persistent cyanosis or failure to ventilate or HR < 60  Depressed respiratory neuromuscular.  Airway malformation.  Lung problem (pneumothorax –diaphragmatic hernia).  Congenital heart disease.

29. Apgar evaluation of newborn Sign 0 1 2 Sign 0 1 2 Heart rate absent 100 Heart rate absent 100 Respiratory effort absent irregular,slow crying, good Respiratory effort absent irregular,slow crying, good Muscle tone limp some flextion active motion Muscle tone limp some flextion active motion Response to catheter no Grimace cough,sneeze Response to catheter no Grimace cough,sneeze Color blue,pale body pink completely pink Color blue,pale body pink completely pink

30. Apgar evaluation of newborn Apgar score is helpful in evaluating patients in need of attention. Apgar score is helpful in evaluating patients in need of attention. Apgar = 0-3 represent either cardiopulmunary arrest, a condition caused by severe bradicardia,hypoventilation, CNS depression Apgar = 0-3 represent either cardiopulmunary arrest, a condition caused by severe bradicardia,hypoventilation, CNS depression Infants born : Infants born : limp, cyanotic, apneic, or pulseless require immediate resuscitation limp, cyanotic, apneic, or pulseless require immediate resuscitation

31. تنها راهي كه به شكست مي‌انجامد، تلاش نكردن است.

32. endotracheal intubation 1. sever respiratory depression who don’t respond to ppv via bag and mask. 2. who was born apneic. 3. Pulseless. 4. Cyanotic and limp 5. Low Apgar score 6. Evidence of a diaphragmatic hernia

33. Neonatal resuscitation Clear of meconium? Clear of meconium? Breathing or crying? Breathing or crying? Good muscle tone? color pink? Good muscle tone? color pink? term gestation? term gestation?  If yes routine care,warmth, clear air way,dry  If no warmth, position, Clear airway, dry, stimulate, reposition, give o2 reposition, give o2 and then Evaluate respiration, HR,and color and then Evaluate respiration, HR,and color routine care,warmth, clear air way,dry

35. Neonatal resuscitation Apnea or HR<100 provide positive pressure ventilation Apnea or HR<100 provide positive pressure ventilation HR 60 HR 60 Provide ppv Provide ppv Administer chest compression Administer chest compression Provide p pv initiate chest compression Initiate medication if < HR 60 After30 sec of p pv and o2 And chest compression Continue p pv ifHR>100 Discontinue p pv color HR>60

36. “Neonatal resuscitation “chest compression If the HR does not improve after 15-30 sec with bag and mask (or endotracheal) ventilation and remains < 60/min If the HR does not improve after 15-30 sec with bag and mask (or endotracheal) ventilation and remains < 60/min or the rate is <80/min and not rising : or the rate is <80/min and not rising :  ventilation + chest compression 120/ min with  ventilation + chest compression 120/ min with com / v = 3/1 com / v = 3/1

37. Chest compressions in Infants(<1 y/o) One finger below intermammary line One finger below intermammary line 3th&4 th fingers on sternum 3th&4 th fingers on sternum 1/3 to1/2 depth of chest 1/3 to1/2 depth of chest 100 times per min. 100 times per min. 5 Compressions to 1 ventilation 5 Compressions to 1 ventilation

38. Chest compressions in Infants(<1 y/o)

39. Cardiac compressions ( infant)

40. براي انسان‌هاي بزرگ، بن‌بستي وجود ندارد زيرا آنها بر اين باورند كه: يا راهي خواهند يافت، يا راهي خواهند ساخت.

42. Assess for signs of circulation Check pulse(3-5 sec.) Check pulse(3-5 sec.) Use brachial or femoral in infants Use brachial or femoral in infants Use carotid in child>8 yr Use carotid in child>8 yr Chest compressions: Chest compressions: neonate =120 1-8yr and>8 =100 neonate =120 1-8yr and>8 =100 Comprassion /ventilation: Comprassion /ventilation: neonate =3:1 1-8yr=5:1 neonate =3:1 1-8yr=5:1 >8yr=15:2 >8yr=15:2

44. Poor response to ventilation in neonates AND children may be due to  - Loosely mask, Positioning of the tracheal tube, air in stomach  - Loosely mask, Positioning of the tracheal tube, air in stomach  -airway obstruction, insufficient pressure, pleural effusion.  -airway obstruction, insufficient pressure, pleural effusion.  asystole, hypovolemia  pneumothorax, diaphragmatic hernia  prolong intrauterine asphexia

45. Medication in Neonatal resuscitation Medications rarely required. Medications rarely required.  Medication should be administered : if HR is < than 60 /min after 30 sec of ventilation and chest compressions. if HR is < than 60 /min after 30 sec of ventilation and chest compressions. During asystole. During asystole.

46. Medication in Neonatal resuscitation  drugs : Epinephrine 0/1 –03 /cc/kg of i/10,000( repeated every 5min) Epinephrine 0/1 –03 /cc/kg of i/10,000( repeated every 5min) Volume expansion isotonic crystalloid Volume expansion isotonic crystalloid Bicarbonate 1-2 m Eq/kg (1mEq/kg/min) Bicarbonate 1-2 m Eq/kg (1mEq/kg/min) Calcium gluconate 2-4cc/kg Calcium gluconate 2-4cc/kg Dopamin and dobutamine in shock Dopamin and dobutamine in shock

47. Intra osseous infusion

49. Chest compressions in child(1-8 y/o ) One fingerbreadth above xyphoid-sternal margin One fingerbreadth above xyphoid-sternal margin Heel of hand Heel of hand Depth:2.5-4 cm. Depth:2.5-4 cm. 100 Times per min. 100 Times per min. 5 Comp. / 1 Vent. 5 Comp. / 1 Vent.

50. Chest compressions

51. Chest compressions in a child

52. Chest compressions in child(>8 y/o) Two hands Two hands Depth : 3-5 cm. Depth : 3-5 cm. 80-100 Times per min. 80-100 Times per min. One rescuer: 5 Comp. / 1 Vent. One rescuer: 5 Comp. / 1 Vent. Two rescuer: 15 Comp. / 2 Vent. Two rescuer: 15 Comp. / 2 Vent.

53. Medication for cardiac arrest Epinephrine 0/01mg/kg iv/ io (1/10000=0/1cc/kg) Epinephrine 0/01mg/kg iv/ io (1/10000=0/1cc/kg) 0/1mg/kg ET (1/1000=0/1cc/kg) 0/1mg/kg ET (1/1000=0/1cc/kg) Administer every3-5min Administer every3-5min Atropine 0/02mg/kg Min dose:0/1mg iv,io,ET Atropine 0/02mg/kg Min dose:0/1mg iv,io,ET Bicarbonate 1mEq/kg infuse slowly if ventilation is adequate Bicarbonate 1mEq/kg infuse slowly if ventilation is adequate Calcium gluconate 60-100mg/kg (0/6-1cc/kg) iv/io Calcium gluconate 60-100mg/kg (0/6-1cc/kg) iv/io Glucose(10%-25%) 2-4cc/kg Glucose(10%-25%) 2-4cc/kg

54. Brain death No spontaneous movement or interaction with enviroment No spontaneous movement or interaction with enviroment No response to stimuli ( pain,light,sound, touch ) No response to stimuli ( pain,light,sound, touch ) Absence of brain stem reflexes Absence of brain stem reflexes Apnea. Apnea. All of the criteria should be present at least 6-24 hr after coma and apnea. All of the criteria should be present at least 6-24 hr after coma and apnea. Silence EEG,no hypothermia and cardiovascular shock and drug intoxication Silence EEG,no hypothermia and cardiovascular shock and drug intoxication

55. Femoral veinanatomy

57. Cardiovascular support Chest compression must be given: Chest compression must be given: 1. If there is no pulse 2. If the pulse is less than 60/min with poor perfusion Chest compressions are given without interrupting ventilation Chest compressions are given without interrupting ventilation

58. "If you love life, life will love you back."! "If you love life, life will love you back." !