Cardiopulmonary Resuscitation Shamiel Salie Paediatric Intensive Care Unit Red Cross Children’s Hospital, University of Cape Town.

Cardiopulmonary Resuscitation

Shamiel SaliePaediatric Intensive Care UnitRed Cross Children’s Hospital,University of Cape Town

BasicLifeSupport

SAFE approach

Are you alright?

Airway opening manoeuvres

Look, listen, feel

5 rescue breaths

Check pulseCheck for signs of circulation

CPR15 chest compressions

2 ventilations

Call emergency services

1 minute

Age Definitions:

• Newborn

• Infant - under 1 year

• Child - from 1 year to puberty

2005 BLS Changes:• Lay rescuers should start compressions for an

unresponsive child who is not breathing/moving

• Universal compression-ventilation ratio of 30:2 for the lone rescuer of infants, children and adults

• Increased evidence on the importance of uninterrupted chest compressions

Compression Compression TechniquesTechniques

Position: for all ages: compress the lower third of the sternum

number of hands:• In infants: two thumbs or two fingers

• in children: use one or two hands: depressing the sternum by approximately one third of the depth of the chest

Chest Compressions

• Push hard

• Push Fast

• Complete chest recoil

• Minimize interruptions

Calling for help!!Calling for help!!• Perform 5 cycles or about 2 minutes of CPR

before calling for help

• Indications for activating EMS before BLS by a lone rescuer are:– witnessed sudden collapse with no apparent

preceding morbidity– witnessed sudden collapse in a child with a known

cardiac abnormality

Choking

Assess

Ineffectivecough

Effectivecough

Conscious Unconscious

5 back blows Open airway

5 chest/abdothrusts

Assess andrepeat

5 rescue breaths

CPR 15:2Check for FB

Encouragecoughing

Support andassess

continuously

Universal Algorithm

Stimulate andassess response

Open airway

Check breathing

5 rescue breaths

Check pulseCheck for signs of circulation

CPR15 chest compressions

2 ventilations

Assessrhythm

Asystole andPEA

VF/VT

Asystole and PEA

Ventilate with highconcentration O2

Adrenaline10 mcg/kg IV or IO

Continue CPRIntubateIV/IO access

4 min CPR

Consider 4 Hs & 4 TsConsider alkalising agents

Check monitorevery 2 minutes

VF/VT

Neonatal Resuscitation

Drugs in Cardiac Arrest

• 10mcg/kg of adrenalin as the first and subsequent iv doses.

• high dose iv adrenalin is not recommended and may be harmful

• Insufficient evidence to recommend for or against the routine use of vasopressin in children

Route of drug delivery in ALSRoute of drug delivery in ALS

• where possible give drugs intra-vascularly rather than via the tracheal route

– lower adrenaline concentrations may produce transient beta adrenergic effects resulting in hypotension.

• Intra-osseous access is safe for fluid resuscitation and drug delivery.

Airway ManagementAirway Management

• guedel airways

• laryngeal airways

• Cuffed or uncuffed endotracheal tubes

Do children have Ventricular fibrillation?

Number of Defibrillating ShocksNumber of Defibrillating Shocks

• one shock rather than three “stacked” shocks

• Modern biphasic defibrillators have a high first shock efficacy

• Most patients have a non perfusing rhythm after successful defibrillation

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AED IN CHILDREN

• Age > 8 years• use adult AED

• Age 1-8 years• use paediatric pads /

settings if available (otherwise use adult mode)

• Age < 1 year• use only if

manufacturer instructions indicate it is safe

Fluid Resuscitation

• Boluses of fluid may be required to maintain systemic perfusion

• Crystalloids - ringers or normal saline

• Septic children may require in excess of 100ml/kg fluid resuscitation

Family Presence during Resuscitation

• Evidence suggests that the majority of parents would like to be present during resuscitation, that they gain a realistic understanding of the efforts made to save the child, and they subsequently show less anxiety and depression.

When do you start?

When do you stop?

• In the absence of reversible causes eg drowning with severe hypothermia, poisoning, prolonged CPR in children is unlikely to result in intact neurological survival.

• One should consider stopping resuscitation after 20 minutes.

Post Resuscitation Care

• Ventilate to normo-capnoea• Hypothermia for 12-24 hours post arrest may

be helpful, whilst hyperthermia should be treated aggressively

• Vaso-active drugs should be considered to improve haemodynamic status.

• Maintain normoglycaemia

Conclusions: • The 2005 guidelines minimizes the differences in the steps

and techniques of CPR used for infants, children and adults.

• Push hard, push fast, minimizing interruptions

• Respiratory failure and hypoxia is the commonest reason for paediatric arrests.

• There are usually warning signs of impending doom, and early and effective therapy will prevent cardiac arrest

Questions