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Pediatric Cardiac Arrest Management

1. Introduction
   1. Newborn
      1. A recently born infant; usually considered the first few hours of life
   2. Neonate
      1. Considered the first 28 days of life
2. Initial Care of the Neonate
   1. Physiologic Response to Birth
      1. Respiratory adaptations
      2. Cardiovascular adaptations
      3. Temperature regulation
   2. Routine care
      1. Support
      2. Dry
      3. Warm
      4. Position
      5. Airway
      6. Stimulation
   3. Assessment
3. Consider Age-Related Variations for Pediatric and Geriatric Patients for Assessment and Management of Cardiac Compromise
   1. Pediatric
      1. Cardiac problems typically associated with congenital heart condition
      2. Cardiovascular compromise often caused by respiratory compromise
4. General pathophysiology, assessment and management
   1. Epidemiology
      1. Incidence
         1. Approximately 6% of deliveries require life support
         2. Incidence of complications increases as birth weight decreases
      2. Morbidity/ mortality
         1. Neonatal mortality risk can be determined via graphs based on birth weight and gestational age
         2. Resuscitation is required for about 80% of the 30,000 babies who weigh less than 1500 grams at birth
      3. Risk factors
         1. Antepartum factors
            1. multiple gestation
            2. inadequate prenatal care
            3. mother’s age <16 or >35
            4. history of perinatal morbidity or mortality
            5. post-term gestation
            6. drugs/ medications
            7. toxemia, hypertension, diabetes
            8. perinatal infections
            9. known fetal malformations/“high risk” OB patient
         2. Intrapartum factors
            1. premature labor
            2. meconium-stained amniotic fluid
            3. rupture of membranes greater than 18 hours prior to delivery
            4. use of narcotics within four hours of delivery
            5. abnormal presentation
            6. prolonged labor or precipitous delivery
            7. prolapsed cord
            8. bleeding
      4. Treatment strategies
         1. Preparation of resuscitation equipment
         2. Determine appropriate destination
   2. Assessment of the newborn
      1. Time of delivery
      2. Normal/ abnormal vital signs
      3. Airway and ventilation
         1. Respiratory rate
         2. Respiratory effort
      4. Circulation
         1. Heart rate
         2. Color/ cyanosis
            1. normal
            2. central versus peripheral
            3. mucosal membranes
         3. End organ perfusion
            1. compare strength of central pulses versus peripheral
            2. capillary refill
      5. APGAR
         1. Appearance - skin color
            1. completely pink - 2
            2. body pink, extremities blue - 1
            3. blue, pale - 0
         2. Pulse rate
            1. above 100 - 2
            2. below 100 - 1
            3. absent - 0
         3. Grimace - irritability
            1. cries - 2
            2. grimaces - 1
            3. no response - 0
         4. Activity - muscle tone
            1. active motion - 2
            2. some flexion of extremities - 1
            3. limp - 0
         5. Respiratory - effort
            1. strong cry - 2
            2. slow and irregular - 1
            3. absent - 0
   3. Treatment
      1. Prior to delivery, prepare environment and equipment
      2. During delivery, suction mouth and nose as head delivers
      3. After delivery
         1. Airway and ventilation
            1. drying
               1. head and face
               2. body
            2. warming
               1. appropriate techniques
               2. minimize heat loss via head
            3. position
            4. suction
               1. technique
                  1. mouth first, than nares
                  2. nasal suctioning is a stimulus to breathe
               2. equipment
                  1. bulb suction
                  2. suction catheters
                  3. meconium aspirator
            5. stimulation
               1. flicking soles of feet
               2. stroking back
            6. blow-by oxygen
               1. never withhold oxygen
               2. oxygen should be warmed
               3. use when
                  1. newborn is cyanotic and
                  2. heart rate > 100 and
                  3. adequate respiratory rate and effort
               4. 5 liters/ minute maximum
                  1. complications due to hypothermia
                  2. direct rather than tangential flow on face
               5. appropriate techniques
            7. bag-valve-mask
               1. mask characteristics
                  1. appropriate size
                  2. minimize dead-space
               2. bag characteristics
                  1. pop-off valve should be disabled
                  2. risk of pneumothorax with excessive pressures
                  3. initial breath may require high pressures
               3. use when
                  1. apneic
                  2. inadequate respiratory rate or effort
                  3. heart rate less than 100
               4. technique
                  1. initial ventilations require higher pressure to expand lungs
                  2. rate
         2. Circulation
            1. vascular access
               1. indications
                  1. to administer fluids
                  2. to administer medications
               2. peripheral vein cannulation
               3. intraosseous cannulation
            2. chest compression (in addition to assisted ventilation with BVM) Refer to current ILCOR/AHA guidelines
         3. Non-pharmacological
            1. temperature control
            2. positioning
         4. Transport consideration
            1. rapid transportation of the distressed infant
            2. position newborn on their side to prevent aspiration
            3. adequate securing of ETT
         5. Psychological support/ communication strategies
5. Specific situations
   1. Meconium stained amniotic fluid
      1. Epidemiology
         1. Incidence
            1. may occur either in utero or intrapartum
         2. Risk factors
            1. fetal distress during labor and delivery
            2. post-term infants
            3. thin particulate meconium versus thick
      2. Anatomy and physiology review
      3. Pathophysiology
         1. Hypoxia or physiologic cause
         2. Aspiration of meconium stained amniotic fluid
            1. Complete airway obstruction
               1. Atelectasis
               2. right-to-left shunt across the foramen ovale
            2. Incomplete airway obstruction
               1. Ball valve type obstruction
               2. developing pneumothorax
               3. chemical pneumonitis
         3. Patient deterioration
            1. hypoxia
            2. hypercapnia
            3. acidosis
      4. Assessment findings
         1. Thin and watery
         2. Thick and particulate
      5. Management considerations for thick or particulate meconium
         1. Airway and ventilation
            1. do not stimulate the infant to breathe
            2. ventilate with 100% oxygen
         2. Circulation
         3. Transport consideration
            1. identify facility to handle high-risk newborn
         4. Psychological support/ communication strategies
            1. do not discuss "chances of survival" with family
            2. explain what is being done for the newborn
   2. Apnea in the neonate
      1. Epidemiology
         1. Incidence
         2. Morbidity/ mortality
         3. Risk factors
            1. prematurity
            2. in newborn, prolonged or difficult labor and delivery
            3. drug exposure
            4. maternal Infection
      2. Anatomy and physiology review
      3. Assessment findings
         1. Failure to breathe spontaneously after stimulation
         2. Respiratory pauses greater than 20 seconds
      4. Management considerations
         1. Airway and ventilation
            1. stimulate the baby to breathe
               1. flicking the soles of the feet
               2. rubbing the back
            2. ventilate with BVM
               1. disable pop-off valve
               2. subsequent ventilations with minimal pressure to cause chest rise
            3. suction as needed
               1. complications
                  1. tube dislodgement
                  2. tube occlusion by mucous or meconium
6. monitor heart rate continuously
7. circulatory access
   1. peripheral iv
   2. intraosseous
      1. Non-pharmacological
      2. Transport consideration
      3. Psychological support/ communication strategies
         1. relatively good outcome if treated early and aggressively
         2. explain what is being done for the infant
8. Bradycardia in the neonate
   1. Epidemiology
      1. Incidence
         1. most commonly caused by hypoxia
         2. increased intracranial pressure
         3. hypothyroidism
         4. acidosis
      2. Morbidity/ mortality
         1. minimal risk if hypoxia is corrected quickly
         2. risk level relative to underlying causation if not due to hypoxia
   2. Anatomy and physiology review
   3. Pathophysiology -- Primarily caused by hypoxia
   4. Assessment findings
      1. Assess upper airway for obstruction
         1. secretions
         2. tongue and soft tissue positioning
         3. foreign body
      2. Assess patient for hypoventilation
      3. Palpate umbilical stump or brachial artery
   5. Management considerations
      1. Airway and ventilation
         1. suction
         2. positive pressure ventilation with 100% oxygen
         3. endotracheal intubation
      2. Circulation
         1. heart rate less than 100 -- BVM ventilation with 100% oxygen and reassess
         2. heart rate less that 60 -- begin chest compressions
         3. heart rate between 60 and 80 but not responding to assisted ventilations with BVM -- begin chest compressions
         4. discontinue chest compressions when heart rate reaches 100
      3. Non-pharmacological -- maintain temperature
      4. Transport consideration -- identify facility to handle high-risk newborn
      5. Psychological support/ communication strategies

Content Creator: Ariel Wei
CAPCE Course Number: 21-EMTP-F3-6102
NJ Course Number: 141125
Total CE Hours: 1
Level: Basic
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