Paediatric Resusatation:

Appearance: TICLS: Tone Irritability, Consolablity, Look (Gaze), Speech (Cry)
Circulation: Cap refill, Colour, Mottling, Cyanosis, Pallor
Work of Breathing: Accessory Muscle Use, Grunting, Nasal Flare, Tripoding, Stridor, Stertor

START

Firstaid treatment of foreign body airway obstruction by back slaps and chest thrusts.
Commencement of basic life support when the victim is “unresponsive and not breathing normally”.
Laypersons
1. should not be taught to attempt pulse palpation to diagnose cardiac arrest.
2. Providers unwilling or unable to give ventilations should give continuous cardiac compressions at a rate of approximately 100 per minute.
Providers of advanced life support
1. should spend no more than 10 seconds attempting to palpate a pulse. If a pulse cannot be palpated with certainty, the rescuer should commence CPR.
2. can commence CPR with 15 chest compressions followed by 2 ventilations in a ratio of 15:2, or alternatively commence with 2 ventilations followed by 15 chest compressions, and aim to accomplish 5 cycles in 1 minute
Providers ofbasic life support
1. should commence CPR with 30 compressions followed by a pause to deliver 2 ventilations and aim to accomplish 5 cycles (repetitions) in 2 minutes.

A – Airway

Assess patency by:
- looking for chest and/or abdominal movement
- listening for breath sounds
- feeling for expired air
Vocalisations, such as crying or talking, indicate ventilation and some degree of airway patency
If there is obvious spontaneous ventilation, note other signs that may suggest upper airway obstruction:
- the presence of stridor
- evidence of recession
If there is no evidence of air movement then chin lift or jaw thrust manoeuvres must be carried out. Reassess the airway after any airway‐opening manoeuvres
If there continues to be no evidence of air movement then airway patency can be assessed by performing an airway‐ opening manoeuvre while giving rescue breaths

Position the head
- neutral position (<1 year old)
  - The trachea is soft and pliable and may be distorted by excessive backward head tilt or jaw thrust.Therefore in infants head should be kept in neutral and maximum head tilt should not be used
- sniffing position ( 1 year of age)
Open airway
- Head tilt
- chin lift
- jaw thrust
Use oropharyngeal airway to maintain airway patency
- Guedel airway
  - ensure correct airway size
    - measure (using guedel) from centre of mouth to angle of mandible
    - too large an airway may push epiglottis posterior and further obstruct the airway
    - too small an airway will push the tongue posteriorly and occlude airway
  - insertion
    - infant/young child
      - insert under direct vision with airway pointing right way up
      - don’t rotate airway in pharynx as mucous membranes very fragile and will bleed
    - older child
      - insert either under direct vision or upside down and rotate 180 degrees

Clearing the airway
- The airway must be cleared of food, saliva, vomit, blood or loose teeth
- If safe to do so manually remove any visible solids using gloved hands
- Use suction if available to clear the airway
- If suction not available roll person on
- side, if safe to do so, and drain fluid from the mouth
- KEY POINT: NO ‘BLIND FINGERSWEEP’ TO CLEAR THE AIRWAY A blind ‘finger sweep’ technique should not be used in children. The child’s soft palate is easily damaged, and bleeding from within the mouth can worsen the situation. Furthermore, foreign bodies may be forced further down the airway; they can become lodged below the vocal cords (vocal folds) and be even more difficult to remove

Airway – Background info

in a young child the
- occiput is relatively large & the neck is short 🡪 when laid flat in the supine position: potentially can result in neck flexion and airway narrowing
- face and mandible are small, and teeth or orthodontic appliances may be loose
- tongue is relatively large 🡪 tends to obstruct the airway in an unconscious child + impede the view at laryngoscopy
- floor of the mouth is easily compressible care in the positioning of fingers when holding the jaw for airway positioning
Infants less than 6 months old:
- are primarily nasal breathers.
- narrow nasal passages are easily obstructed by mucous secretions
- upper respiratory tract infections are common in this age group
- these children are at particular risk of airway compromise.
between 3 and 8 years
- Adenotonsillar hypertrophy
- can cause obstruction
- can cause difficulty when the nasal route is used to pass pharyngeal, gastric or tracheal tubes.
all young children
- epiglottis:: horseshoe‐shaped, and projects posteriorly at 45°, making tracheal intubation more difficult.
- Larynx:: is high and anterior
- C2-3 in the infant ( compared with the C5-6 in the adult)
- easier to intubate an infant using a straight‐blade laryngoscope
- Cricoid ring:: oval in shape
passage of a round endotracheal tube will almost always result in a leak around the tube.
if there is not a leak at pressures of approximately 20 cmH2O, it is likely that that tube is too large.
Although uncuffed endotracheal tubes have been used preferentially in children, there is increasing evidence that cuffed endotracheal tubes may be advantageous in many settings
cuffed tube requires meticulous attention to :
- size
- cuff pressure
- exact placement of the endotracheal tube in the correct position
- trachea:: is short and soft
- Overextension of the neck as well as flexion may therefore cause tracheal compression.
- The short trachea and the symmetry of the carinal angles mean that not only is tube displacement more likely, but a tube or a foreign body is also just as likely to be displaced into the left as the right main‐stem bronchus.

B – Breathing

A patent airway does not ensure adequate ventilation.
The latter requires an intact respiratory centre and adequate pulmonary function augmented by coordinated movement of the diaphragm and chest wall.
Signs of respiratory inadequacy
- Tachypnoea
- Increased work of breathing (intercostal, subcostal or suprasternal recession; use of accessory muscles)
- Respiratory noises (wheeze, stridor, grunting)
- Desaturation (SpO2 < 92%)
- Reduced chest expansion
- Reduced air entry
- Cyanosis
- Secondary signs:
  - tachy or bradycardia
  - colour change pale or blue
  - cool peripheries
  - altered mental stateIf respiration is adequate
  - administer oxygen by facemask at 10 l/min.

LOOK, LISTEN, FEEL
If respiration is adequate
- administer oxygen by facemask at 10 l/min.
- Do not use selfinflating bags in spontaneously ventilating patients They are designed to deliver O2 only if squeezed.
If the child is not breathing
- commence artificial ventilation.
Artificial ventilation
- Select the appropriate sized resuscitator bag
  - Premature neonate – 250ml
  - Infant up to 2 years 500 ml bag
  - Child/adult > 2 years 2 litre bag
- Select an appropriate sized mask.
- Obtain an airtight seal

O2 flow rate of 1015 l/min and attachment of a reservoir assembly will give nearly 100% O2.
An oropharyngeal airway will facilitate maintenance of the airway and bag and mask ventilation.
Brief suction of the mouth and pharynx if needed, using a yankeur sucker under direct vision
Ventilate to have normal chest rise and fall.
Do not over ventilate
Intubation should only be attempted by those credentialed and skilled to do so
In spontaneously breathing patients ensure synchrony with patient effort.
Regardless of how effective bagvalvemask ventilation is achieved, some degree of gastric inflation will occur. If the abdomen becomes distended with bagvalvemask ventilation, the passage of a nasogastric tube may be required to decompress the stomach.

Endotracheal intubation RSI 7 Ps

Preparation
1. People
2. Equipment
  1. Suction
  2. Oxygenation
  3. Equipment
  4. Medication
  5. Airway
    1. Blade:
      1. Miller: Thinner, straight, preferred for infants and young children, facilitates lifting of the epiglottis and exposing the glotic opening, Placed on top of glottis lifting away, possibly better control of tongue
      2. Mac: wider, curved blade, tend to be used for older kids and adults, Curves around the tongue, placed into vallecular and lift away, Possibly Wider glottis opening

Premature infant	0 Miller
Infant	1 Miller
Child 2-6 yrs	2 Miller
Child 6-12	2 Macintosh
> 12yrs	3 Macintosh
As per The Emergency Medicine Manual;Dunn

Select the correct tube size:

neonatal trachea is only 4cm in length

Older than 1 year: Tube size (mm) = (age in yr/4) + 4

Length at lip (cm) = (age in yr/2) + 12

Age	Weight (kg)	Tube size (mm)	Length at lip (cm)
Newborn	3.5	3	8.5
2 months	5	3.5	9
6 months	8	4	10
1 year	10	4	11
As per APLS

Assess LEMON
1. Look – short neck, large tongue, micrognathia
2. Facial anatomy – Pierre Tobin, cleft lip/palate, Downs, Goldenhar, Buck teeth, missing teeth
3. Evaluate – 3 – 3 – 2
4. Mallampati
5. Obstruction
6. Neck mobility

PreOxygenation
1. 100% FiO2 5 mins
Pretreatment
Put to Sleep
1. Propofol, Ketamine,Fentanyl
Paralyse
1. Sux/Roc
Pass tubeInsertion technique
1. avoid hyperextension of the neck (as in adults) during intubation
2. straight Miller blade used posterior to the epiglottis
  1. traditionally preferred in children < 6 years of age
  2. more recent evidence questions the advantage of the Miller blade in improving laryngeal visualisation compared over a Macintosh in children < 2 years of age
3. curved Macintosh blade used anterior to epiglottis (as in adults)
  1. care required with blade insertion as the high anterior floppy mass of mandibular tissue and epiglottis may fill the field
  2. use bigger rather than smaller blade to assist vision
4. may use an uncuffed or cuffed (short term) endotracheal tube
  1. old school
    1. uncuffed for under 8 years to help prevent subglottic stenosis and avoid post extubation stridor(2 studies dating back 1994 and 2004)
  2. current teaching
    1. cuffed tubes universally preferred
    2. enables better oxygenation/ventilation
    3. better for severe lung disease
5. have 1/2 size larger and smaller tubes ready
6. decrease size by 0.5mm if severe croup or epiglottitis suspected
7. tube diameter approximated by
  1. diameter of the patient’s little finger
  2. length of patient (most accurate as in Broselow system)
8. aim to have small air leak at airway pressures of 2025 mmHg to avoid subglottic trauma which may lead to postextubation oedema and obstruction
9. aim to keep airway pressure < 30 mmHg
10. gastric decompression via NGT mandatory due to diaphragm splintage
11. use orogastric tube in major head injury
12. convert to nasotracheal tube in infants once stable to help stabilise the tube
13. After tracheal intubation, if Bag/Mask: ventilation should be restricted to approximately 10 breaths per minute

Placement verification
1. Capnography
2. EtCO2
3. Auscultation
4. Mist
5. Chest rise
6. Chest Xray

Difficult airway
- laryngeal mask sizes 1, 1.5, 2, 2.5 suitable alternative to ETT from newborn
- cricothyroid puncture preferred to cricothyroidotomy in children < 12 years of age
- Initial ventilator settings

tidal volume (volumecontrolled ventilator): 6 mL/kg

newborn 20mL/ 50 breaths/min.

6 months 48mL/ 40 breaths/min.

1 year 60mL/ 35 breaths/min.

2 years 78mL/ 25 breaths/min.

4 years 90mL/ 20 breaths/min.

6 years 120mL / 16 breaths/min.

12 years 240mL/ 16 breaths/min.

PIP (pressurecontrolled ventilation)

newborn (well) = 15 cm H₂O (RDS) = 25

child = 20 25 cm H₂O

PEEP 3-5 cm H₂O

I:E ratio = 1:2

FiO₂ 100%

Breathing – b/g info

Lungs are relatively immature at birth.
The air–tissue interface has a relatively small total surface area in the infant (less than 3 m2).
10‐fold increase in the number of small airways from birth to adulthood.
Both the upper and lower airways are relatively small, and are consequently more easily obstructed.
As resistance to flow is inversely proportional to the fourth power of the airway radius (halving the radius increases the resistance 16‐fold), seemingly small obstructions can have significant effects on air entry in children
Therefore much of the respiratory disease in children is characterised by airway obstruction.
Chest wall
- Increase in chest wall compliance and reduction in lung compliance due to smaller numbers of alveoli.
- Reduced ‘functional residual capacity‘
- This promotes collapse and lower residual volumes.
- This combination of factors leads to rapid desaturation.

Infants rely mainly on diaphragmatic breathing.
- Muscles are more likely to fatigue
- As they have fewer type i (slow‐twitch, highly oxidative, fatigue‐resistant) fibres compared with adults.
- Pre‐term infants’ muscles have even less type i fibres. These children are consequently more prone to respiratory failure.
- The ribs lie more horizontally in infants
- Contribute less to chest expansion.
- In the injured child, the compliant chest wall may allow serious parenchymal injuries to occur without necessarily incurring rib fractures.
- For multiple rib fractures to occur the force must be very large; the parenchymal injury that results is consequently very severe and flail chest is tolerated badly.

C– Circulation

Signs of circulatory inadequacy
- Tachycardia
- Hypotension and Bradycardia is a late and preterminal sign
- Delayed capillary refill
- Reduced pulse volume
- Secondary signs
  - tachypnoea (especially if no increased work of breathing)
  - bradypnoea
  - altered conscious state
  - colour change Pallor or cyanosis

Cardiorespiratory arrest should be suspected when the infant or child is unresponsive and not breathing normally 🡪 Commence chest compressions
Spend no longer than 10 sec feeling for a pulse
- “Pulse check may be used but should not delay CPR for more than 10 seconds” anzcor guidelines
CPR
- “For a single rescuer and an unwitnessed collapse, commence CPR before seeking help” anzcor guidelines
- “For a witnessed collapse and/or multiple rescuers call for help immediately and then start CPR ” anzcor guidelines
External cardiac compression
- “For infants and children, CPR should commence with 2 ventilations ” anzcor guidelines
- Basic life support rescue:
  - Single or two basic life support rescuers
    - Compression ventilation ratio of ratio of 30:2 with pauses for ventilation.
    - rate : 100-120 per minute.
    - Aim for 5 in two minutes
- Advanced life support rescue:
  - Ventilation compression ratio of 15:2 should be used
  - There should be pauses for ventilation when using bagvalvemask ventilation or a laryngeal mask airway.
  - rate : 100-120 per minute.
  - Aim for 5 in two minutes
- DO NOT interrupt except for defibrillation.
- Place the child on a firm surface. If on a bed, place the cardiac massage board under the patient, not under the mattress
- Apply massage to the lower half of the sternum in all patients including newborns
- Compress sternum 1/3 the depth of the chest.
- Use the hand technique that allows you to achieve this see examples pictures
  - Infant < 1 year:
    - Single rescuer: 2 fingers
    - Two rescuers: Two thumbs encircling
  - Child 1-18yrs:
    - use the “heel” of one hand with the other superimposed.
    - For small children use the heel of one hand

Gain IV or IO access as soon as possible
- at least the second dose of adrenaline should be given via this route
- The endotracheal route is an acceptable alternative for adrenaline (100 microgram/kg), atropine and lignocaine if the intravenous and intraosseous access to
- Pulseless nonshockable cardiac dysrhythmias should be treated with adrenaline 10mcg/kg intravenously via the intraosseous route.
- Amiodarone is for refractory VF.
- Adrenaline for severe bradycardia, asystole and pulseless electrical activity the circulation is impossible.
Frequent changes of personnel (every few minutes) is desirable
During resuscitation do not stop to check for a pulse unless the ECG shows an organised rhythm.
After DC shock continue CPR for 2 minutes prior to checking rhythm

If desired by family, their presence at resuscitation of their child is encouraged.
Therapeutic hypothermia is acceptable after resuscitation to improve neurological outcome.
Extracorporeal circulatory support for inhospital cardiac arrest may be used in equipped centres

During resuscitation: Correct treatable causes

Hypoxaemia
Hypovolaemia
Hypo/hyperthermia
Hypo/hyperkalaemia
Tamponade
Tension pneumothorax
Toxins/poisons/drugs
Thrombosis

Circulation – background info

At birth the two cardiac ventricles are of similar weight
by 2 months of age the RV : LV weight ratio is 0.5.
These changes are reflected in the infant’s electrocardiogram (ECG)
During the first months of life the right ventricle (RV) dominance is apparent
by 4–6 months of age the left ventricle (LV) is dominant
As the heart develops during childhood, the sizes of the P wave and QRS complex increase, and the P‐R interval and QRS duration become longer
Increased vagal tone makes bradycardia and hypotension common post induction.
Cardiovascular stability is dependent on heart rate (LV stroke volume is fixed)
circulating blood volume per kilogram of body weight (70–80 ml/kg) is higher than that of an adult
but the actual volume is small.
This means that in infants and small children, relatively small absolute amounts of blood loss can be critically important.
cardiac arrest out of hospital = outcome generally poor

cardiac arrest is rarely related to cardiac arrhythmia
commonly is a sequel of
- Respiratory Obstruction leading to hypoxia/ hypoxaemia
  - birth asphyxia
  - inhalation of FB
  - bronchiolitis
  - asthma
- Respiratory depression
  - raised ICP
    - head injury
    - acute encephalitis
- Fluid loss/Fluid Maldistribution leading to shock with associated organ damage and dysfunction
By the time that cardiac arrest occurs, there has already been substantial damage to various organs

D Disability (neurological evaluation)

	Corresponding GCS
A Alert	11-15
V Responds to Voice	5-15
P Responds only to Pain	4-12
U Unresponsive to all stimuli	3-5

Consider intubation to stabilise the airway in any child with a conscious level recorded as P or U (only responding to painful stimuli or unresponsive).
Intravenous lorazepam, buccal midazolam or rectal diazepam should be given for prolonged or recurrent fits
Manage raised intracranial pressure if present

E Exposure

Manage Hypothermia
Check for rash etc..

G Glucose

If hypoglycaemia has been found, treat hypoglycaemia with a bolus of glucose (2 ml/kg of 10% glucose) followed by an IV infusion of glucose

Drug therapy in Resuscitation

Adrenaline
- 10 µg/kg (0.1 mL/kg 1:10,000) IV/IO
- 100 µg/kg (0.1 mL/kg 1:1,000) ETT
- high dose adrenaline confers no survival advantage
- adrenaline preferable to dopamine as inotropic agent
Amiodarone
- 5 mg/kg
Atropine
- for persistent asystole / bradycardia
- 0.02 mg/kg (min 0.1 mg, max 0.6 mg) IV/IM
- too small a dose of atropine can lead to paradoxical, centrally mediated bradycardia
Lignocaine
- Never give lignocaine after Amiodarone
- Amiodarone is the preferred agent
- Same indications as Amiodarone. Dose (1mg/kg) (0.1ml/kg of 1%)
Magnesium Sulphate
- For hypomagnesaemia or for polymorphic VT (torsade de pointes)
- 50% solution: 0.050.1ml/kg (0.10.2mmol/kg) (max 2 g)
- Infuse over 5 mins.
HCO3
- 1 mmol/kg stat if pH < 7.1
Adenosine
- 0.1 mg/kg first dose
- increase to 0.2 mg/kg then 0.3mg/kg (max 12 mg) if required
Suxamethonium
- neonate 3 mg/kg
- child 2 mg/kg
- adult 1.5 mg/kg
Vecuronium
- 0.1 mg/kg
Diazepam
- 0.2 mg/kg
Midazolam
- 0.15 mg/kg
Glucose
- 0.2 0.5 g/kg (2 5 mL/kg 10%)

Routes of administration

IV preferable, intraosseous next preferred
endotracheal administration at 10 times the normal dose
central venous administration not routinely recommended due to difficulty of access

Post resuscitation care

Outcome of cardiac respiratory arrest in children
- outcomes from resuscitation are worse than in adults
- survival rates as low as 9% to hospital discharge
- survival higher in
  - PEA (20%)
  - VF (10%)
Ensure airway and breathing are managed effectively including intubation if not already performed. Do not extubate. Use adequate sedation and analgesia.
Ventilate to normo carbia
Circulation maintain adequate blood pressure with use of inotropes as needed. Monitor for further arrhythmias.
Aim for core temperature of 35 degrees (do not actively warm if core temp >32 degrees)
Ensure normo glycaemia

Paediatric Resusatation:

A – Airway

B – Breathing

Breathing – b/g info

C– Circulation

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A – Airway

B – Breathing

Breathing – b/g info

C– Circulation

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