PEDIATRIC ADVANCE

Submitted To Submitted By
Madam N. Saha Puspita Roy
Professor College Of Nursing
College Of Nursing R. G. Kar Medical College
R. G. Kar Medical College and Hospital
and Hospital
INTRODUCTION
Pediatric specialties are rapidly developing in the country. Pediatric intensive care is an
important specialty among these. In India, few centers in government and private medical
colleges have developed separate Pediatric Intensive Care Units (PICU); the numbers of
hospitals now offering pediatric intensive care is increasing, though most are in the private
sector.
Cardiac arrest, also called cardiopulmonary arrest or pulseless arrest, is the cessation of
circulation of blood as a result of absent or ineffective cardiac mechanical activity. Clinically, the
patient is unresponsive, apneic, with no detectable pulse. Cardiac arrest is not uncommon; about
2% children in Pediatric Intensive Care Unit (PICU) develop sudden cardiac arrest during their
stay in PICU and there are approximately 8-20 out of hospital arrests/100,000 children per year
in USA.1.2 Approximately, one fourth of children survive to hospital discharge following
treatment for in hospital arrest and same is 8% for out-of-hospital arrest among children. The
survival after in-hospital cardiac arrest in children had increased to 39% in a recent study. About
65-75% children, who survive to discharge after in-hospital cardiac arrest, had good neurological
outcome. Time to start CPR after arrest and quality of CPR are important among critical factors
which determine survival after arrest. The cardiac arrest can be divided into four phases for
interventions to improve the final outcome: pre-arrest, untreated cardiac arrest, CPR (low flow
phase) and post resuscitation phase.
Pediatric Advanced Life Support (PALS) is a set of evidence-based guidelines for the emergency
treatment of children and infants during life-threatening situations. Developed by the American
Heart Association (AHA), PALS aims to provide healthcare professionals with the knowledge
and skills necessary to recognize and manage pediatric emergencies effectively.

PALS training covers various aspects of pediatric resuscitation, including:

Basic Life Support (BLS):

Basic life support is the technique to oxygenate the brain heart and lungs until the appropriate
medical treatment can restore normal function of brain heart and lungs. Proper techniques for
cardiopulmonary resuscitation (CPR), including chest compressions, rescue breathing, and the
use of automated external defibrillators (AEDs) in children and infants.
Advanced Life Support (ALS):
Advanced techniques for managing pediatric cardiac arrest, including airway management,
intravenous (IV) access, medication administration, and defibrillation.
Pediatric Assessment:
Systematic assessment of pediatric patients to identify and prioritize life-threatening conditions
promptly.
Recognition and Management of Respiratory Emergencies:
Assessment and treatment of respiratory distress, respiratory failure, and conditions such as
asthma and croup.
Recognition and Management of Shock:
Identification and management of various types of shock, including hypovolemic, distributive,
cardiogenic, and obstructive shock in pediatric patients.
Recognition and Management of Arrhythmias:
Identification and treatment of common pediatric arrhythmias, such as bradycardia, tachycardia,
and pulseless arrest.
Post-Resuscitation Care:
Supportive care following successful resuscitation, including monitoring, stabilization, and
transport to an appropriate healthcare facility for further treatment.

PEDIATRIC ADVANCED LIFE SUPPORT

DEFINITIION:
Pediatric advanced life support (PALS) can be provided in the setting of an organized
response in an advanced healthcare environment where multiple responders are capable of
simultaneous coordinated action. While two main rescuers perform chest compressions and
ventilations, other rescuers obtain a monitor/defibrillator, establish vascular access and prepare
the anticipated medications.
Pre-Arrest Phase
It is the crucial phase to prevent cardiac arrest, therefore, decreasing mortality Candia
morbidity from cardiac arrest. In children, cardiac arrest is most often caused by progression of
respiratory distress, respiratory failure, or shock than primary cardiac arrhythmias. Two
presentations of Cardiac arrest in children are: hypoxic/asphyxia arrest (common) and sudden
cardiac arrest [uncommon, usually associated with Ventricular Fibrillation (VF) or pulseless
Ventricular Tachycardia (VT)]. Asystole and bradycardia with a wide QRS complex are most
common in asphyxial cardiac arrest."
Meticulous monitoring of all admitted children is critical for such purpose. Pediatric early
warning scores (PEWS) may be used to identify such patients before arrest to do effective
intervention. Creation and implementation of pediatric medical emergency teams (MET) to
respond in imminent decompensation situations had shown to decrease cardiac arrest and
mortality significantly.
American Heart Association (AHA) has given recommendations in 2015 regarding use of
atropine and extracorporeal membrane oxygenation (ECMO) in critically ill children. These
guidelines do not recommend routine use of atropine before emergency intubation in children
and if atropine is used, the dose is 0.02 mg/kg without a minimum dose. Venoarterial
extracorporeal membrane oxygenation (ECMO) may be used in children with fulminant
myocarditis having risk of impending cardiac arrest.

Cardiac Arrest and CPR Phase

Early recognition of pulseless arrest and prompt initiation of high-quality CPR is
undoubtfully the best measure to improve survival from cardiac arrest.
As cardiac arrest in children is a result of progressive hypoxia and/or shock, initial best
intervention of choice is prompt and high-quality CPR. Once cardiac arrest is detected, start CPR
in C-A-B (Compressions- Airway-Breathing) sequence immediately. The characteristics of high-
quality CPR are shown in Table 1.6 Hyperventilation and interruptions in chest compression are
not uncommon during CPR and contribute to poor outcome after arrest.
Characteristics of high-quality CPR

Characteristics Criteria

1. Push hard Compress at least one-third of anterior-

posterior diameter of chest; 1.5 inch (4 cm)
for infants and 2.0 inch (5 cm) for children,
after puberty use adult depth i.e. at least 5 cm
but not more than 6 cm
 2. Push fast Chest compression rate of 100/min to
120/min Allow chest to return to original
position before next compression
3. Allow full chest recoil between Allow chest to return original position before
compression next compression
4. Minimum interruptions in chest Give two breaths within 10 s while giving
compression chest compressions and breathing. Check
pulse during CPR within 5-10 s and resume
CPR immediately if pulse is absent
5. Avoid hyperventilation Give the breath to cause just visible chest rise.
With advanced airway, ventilate at a rate of
20-30/min

Both chest compressions and breathing are recommended for pediatric CPR. Compression only
CPR is inferior to conventional CPR (both compressions and breathing) for children, but it can
be used in out of hospital arrest, if rescuer is hesitant in giving breath. The ratio of chest
compressions to breathing is 30:2 for single rescuer and it is 15:2 for two rescuers in pediatric
CPR (after infancy till onset of puberty). Once an advanced airway is secured, give continuous
chest compressions at a rate of 100-120 per minutes without pauses for ventilation, that is, at a
rate of 8-12/minutes. Rotate the compressor role, approximately every 2 minutes to prevent
compressor fatigue and deterioration in quality and rate of chest compressions.
If already in place, end-tidal CO2 (ETCO₂) and arterial line blood pressure monitoring may be
used to determine quality of chest compressions, though there is lack of specific values for
pediatric patients.
After starting CPR, provide oxygen to the patient and attach ECG
monitor or defibrillator to identify the arrest rhythm. The cardiac arrest is associated with one of
the following rhythms, also known as arrest rhythm.
• Asystole
• Pulseless electrical activity (PEA)
• Ventricular fibrillation (VF)
• Pulseless ventricular tachycardia.

Determine the rhythm whether it is "Shockable" (i.e., VF or pulseless VT) or "Non-shockable"

(i.e., asystole or PEA) as further management differs for each type of rhythm.

"Shockable Rhythm": Ventricular Fibrillation/Pulseless VT

 Ventricular fibrillation (VF) is a chaotic, disorganized series of depolarization that results
in a quering myocardium without organized contractions. VF occurs in 5% to 15% of all
pediatric victims of out-of- hospital cardiac arrest and is reported ported in up to 20% of
pediatric in-hospital arrests at some point during the resuscitation. Survival to discharge is better
for first documented VF or VT as compared to secondary VF and VT developing during CPR
with initial asystole or PEA. Defibrillation is the definitive treatment for VF with an overall
survival rate of 17% to 20% The defibrillation can lead to PEA, asystole, or organized electrical
activity. The purpose of defibrillation is to abort chaotic rhythm and return of organized rhythm
with palpable pulse. Use a dose of 2-4 J/kg for the first attempt and 4 J/kg for subsequent
attempts. Subsequent doses for defibrillation may be increased, if there is no response, to a
maximum 10 J/kg (or 300 Joule) adult dose.
Give one shock (2-4 J/kg) as quickly as possible and immediately resume CPR. Give 5 cycles of
CPR in 2 minutes. Check the rhythm. If a shockable rhythm persists, give 2nd shock (4 J/kg),
resume CPR Immediately. Give a dose of adrenaline. Use a standard dose of adrenaline [0.01
mg/kg IV/IO (1: 10,000; 0.1 ml/kg) or 0.1 mg/kg through endotracheal tube (1: 1,000; 0.1
ml/kg)] for the first and subsequent doses Repeat adrenaline about every 3 to 5 min during
cardiac arrest. After 5 shoes of CPR, check the rhythm. If the rhythm continues to be
“shockable", deliver a shock (4 J/kg), resume CPR immediately, and give amiodarone (5 mg/kg
as a bolus) or lidocaine (1 mg/kg). Continue CPR for 5 cycles before again checking the rhythm
and attempting to defibrillate needed with 4 J/kg (maximum 10 J/kg or 300J). If there is an
organized rhythm at any time, check for a pulse and if pulse is present, begin resuscitation care.
If defibrillation is successful but VF recurs, continue CPR while you give another bolus of
amiodarone before you to try to defibrillate with the previously successful shock dose. Search for
and treat reversible causes.
"Non-Shockable Rhythm": Asystole/PEA
The most common ECG findings in infants and children in cardiac arrest are asystole and
PEA. PEA is an organized electrical commonly slow, wide QRS complexes-without palpable
pulses. This subcategory [formerly known as electromechanical dissociation (EMD) more likely
to be treatable. For asystole and PEA: resume CPR and continue with minimum interruptions in
chest compressions. A second rescuer gives adrenaline while the first rescuer continues CPR.
Use a standard dose of adrenaline for the first and subsequent doses. Search for and treat
reversible causes.
If feasible, family members may be allowed to be there during CPR but a person should be there
to explain the CPR and to answer their queries. Routine calcium is not recommended during
CPR unless there is documented hypocalcemia, hyperkalemia, hypermagnesemia, or calcium
channel blocker overdose. Similarly, sodium bicarbonate is not recommended during CPR except
in case of hyperkalemia or sodium channel blocker (tricyclic antidepressants).
Post-Resuscitative Phase
After return of spontaneous circulation (ROSC), there is a risk of brain injury,
arrhythmias and re-perfusion injury. Hyperthermia following brain injury or cardiac arrest is not
uncommon in children and is associated with bad neurological outcome; therefore fever should
be managed aggressively after ROSC. AHA recommends to maintain 5 d of continuous
normothermia or 2 d of initial hypothermia (temperature between 32°-34°C) followed by 3 d of
normothermia (36°-37.5°C in children who remain comatose after out-hospital cardiac arrest.
Recent AHA update also recommend targeted temperature management of initial hypothermia
followed by normothermia for in hospital cardiac arrest in children based on a RCT. 11. 12 After
ROSC, intravenous fluids and/or inotropes/vasopressors should be used to maintain systolic
blood 5th centile. If available, invasive arterial line may be used to monitor blood pressure.
Similarly, normal oxygen saturation with oxygen pressure above saturation between 94%-99%
(avoid both hypoxia and hyperoxia) and normal PaCO2 (avoid both severe hypercapnia and
hypocapnia) should be post-resuscitation phase targeted in There are many factors that determine
the outcome after ROSC and single parameter should not be used for prognostication, POSC and
duration of CPR is associated with poor outcome. Reactive pupils after 24 h of arrest are found
to have good survival outcome.
Extracorporeal Membrane Oxygenation (ECMO)
There are reports of increased survival after placing children on ECMO during CPR. 15.
16 About one-third children getting ECMO-CPR survived to hospital discharge in these studies.
Early and high-quality CPR along with underlying cause of cardiac arrest are crucial factors that
determine outcome after ECMO-CPR. The ECMO-CPR is more beneficial in children with
underlying cardiac diseases.
Monitoring
Respiratory failure: A respiratory rate of less than 10 or greater than 60, diminished breath nasal
flaring, retractions, seesaw breathing, or grunting and cyanosis are ominous signs of impending
respiratory failure in children. Shock-Signs of compensated shock include tachycardia, cool and
pale distal extremities, prolonged capillary refill and weak peripheral pulses, compared with
central pulses. Decompensated shock manifests pallor, peripheral cyanosis, tachypnea, mottling
of the skin, decreased urine output, metabolic acidosis, depressed mental status, weak or absent
peripheral pulses, weak central pulses and hypotension
Airway and Breathing
Maintain an open airway by placing oropharyngeal and nasopharyngeal airways, which displaces
the tongue or soft palate from the pharyngeal air passages. Laryngeal mask airway may be used
provide a patent airway and support ventilation. Suctioning should be done, if necessary.
• Oxygen: It can be administered by face mask, nasal canula, endotracheal intubation. Use
pulse oximetry to assess oxygen saturation.

• Bag-mask ventilation: It requires correct size of mask, tight seal between the mask and
face, patent airway and ventilation to be very effective. Deliver each breath with an
inspiratory time of approximately 1 sec if the child is not intubated. If the infant or child
is intubated, ventilate at a rate of about 1 breath every 6-8 sec (8-10 times per minute)
without interrupting chest compressions.

• Ventilation with an endotracheal tube: Confirm correct position of the ET tube by

using of end-tidal carbon dioxide monitor or colorimetric device Use a maximum suction
force of 80-120 mmHg for suctioning the airway via an endotracheal tube.

• Extracorporeal Life Support (ECLS): Extracorporeal Circulation life support (ECLS)

is a modified form of cardiopulmonary bypass used to provide prolonged delivery of
oxygen to tissues in a highly supervised environment.
Circulation:
Perform ECG, echocardiography, continuous capnography or capnometry monitoring.
• Vascular access: It is required for administering medications and drawing blood samples.
Venous access and intraosseous access is used. Intraosseous vascular access is safer and
effective and should be initiated in the proximal tibia or distal femur. All intravenous
medications can be administered intraosseous and blood samples can be obtained for type
and cross match and blood gases during CPR. Peripheral or central venous access can be
used for administering medication.
• Endotracheal drug administration: If vascular access is not available, lipid-soluble
drugs, such as lidocaine, epinephrine, atropine, and naloxone can be administered via an
endotracheal tube. Non-lipid-soluble drugs (e.g., sodium bicarbonate and calcium) should
not be administered via the endotracheal route as they may injure the airway.
Emergency Fluids and Medications
Fluids
• Crystalloid solution for fluid loss: Normal saline 20 mL/kg bolus over 20 min, ringers
lactate.
• Blood loss: Colloid: 5% albumin, blood, fresh frozen plasma.
Medications
Adenosine, amiodarone, atropine, calcium, epinephrine, lidocaine, magnesium, procainamide,
sodium bicarbonate, vasopressin.
Pulseless Arrest
Asystole
• CAB: Start CPR
• Give oxygen when available
• Attach monitor/defibrillator
• Check rhythm /check pulse
• If asystole give epinephrine 0.01 mg/kg of 1:10,000
• Resume CPR may repeat epinephrine every 3-5 min until shockable rhythm is seen
VF and VT
• Start CAB
• Give oxygen
• Attach monitor/defibrillator
• Check rhythm: VF/VT
• Give one shock at 2 J/kg
 • If still VF / VT, give 1 shock at 4 J/kg
• Give epinephrine 0.01 mg/kg of 1:10,000
• Consider: Amiodarone at 5 mg/kg
Bradycardia
This is the most common dysrhythmia in the pediatric population and may be caused due to
hypoxemia. Administer oxygen, attach an ECG monitor/ defibrillator, and obtain vascular access.
If heart rate is 60 beats minute with poor perfusion despite effective ventilation with oxygen start
CPR. If this does not work IV or IO Epinephrine 0.01 mg/kg ( not recommended in ET tube 0.1
mg/kg)
Tachycardia
Administer oxygen, attach an ECG monitor/ defibrillator, and obtain vascular access. Attempt
vagal stimulation. In infants and young children, apply ice to the face without occluding the
airway. In older children, carotid sinus mas- sage or valsalva maneuvers may be done safely.
Pharmacologic cardioversion with adenosine may be effective.
Post resuscitation Stabilization (Post Cardiac Arrest Care)
Goals

• To preserve neurological function.

• To prevent secondary organ injury.
• To diagnose and treat the cause of illness.
• To enable the patient to arrive at a pediatric tertiary-care facility.

Care

• Re-assessment of status is ongoing.

• Laboratory and radiologic information is obtained.
• Control pain and discomfort with analgesics (e.g., fentanyl or morphine) and sedatives
(e.g.: lorazepam or midazolam).
• Therapeutic hypothermia (32-34°C) may be considered for children who remain
comatose after resuscitation from cardiac arrest.
• Etiology of respiratory failure or shock is determined.

(7Hs- hypothermia, hyperkalemia/ hypokalemia, hypotension, H2 ion acidosis,

hypoglycemia, hypovolemia, hypoxia)
(5Ts- tablets/ toxins, tension pneumothorax, cardiac tamponade, thromboembolism,
thrombosis, trauma)
• Transfer to facility where child can get maximum care.
Foreign body aspiration, poisoning, drowning, and near drowning, hemorrhages, burn are the
most common causes to provide the PALS in the life threatening condition.

Medicine Mode of action Dosage Remarks

Increase heart rate, 0.01 mg/kg (0.1 May repeat every 3-5 min
peripheral vascular ml/kg 1:10,000)
resistance and cardiac IV/IO 0.1 mg/kg (0.1
Epinephrine
output. During CPR ml/kg 1:1000) ET
increase myocardial and Maximum dose 1 mg
cerebral blood flow. IV/IO; 2.5 mg ET
Slows AV nodal and 5 mg/kg IV/10; may Monitor ECG and blood;
ventricular conduction, repeat twice up to 15 adjust administration rate
Increase the QT Interval mg/kg Maximum to urgency (IV push during
and may cause single dose 300 mg cardiac arrest, more slowly
vasodilation. over 20- 60 mi with perfect
Amiodarone rhythm).
Used in atrial and
ventricular
antiarrhythmic, pulseless
arrest.

Blocks AV node 0.1 mg/kg (maximum Monitor ECG Rapid IV/IO

conduction for a few 6 mg) bolus with flush
seconds to interrupt AV
node re-entry. Used in Second dose: 0.2
Adenosine
tachycardia with pulses mg/kg
after synchronized
cardioversion. (maximum 12 mg)

Increases glucose in 0.5-1 g/kg IV/IO

hypoglycaemia Newborn:
Glucose 5-10 mL/kg D10W -
Infants and Children:
2-4 mL/kg D25W
 Medicine Mode of action Dosage Remarks

Adolescents:
1-2 mL/kg D50W
Opiate antagonist: 0.2 mg/kg <5 years
Reverses respiratory 0.2
Naloxone -
depression effects of mg/kg >5 years IV/IO
narcotics.
pH buffer for prolonged 1 mEq/kg per
arrest, hyperkalemia dose IV/IO slowly
Sodium bi
increases blood pH -
carbonate
helping to correct
metabolic acidosis.
Parasympatholytic drug 0.02 mg/kg IV/ΙΟ Higher doses may be used
that accelerates sinus or 0.04-0.06 mg/kg ET with
atrial pacemakers and organophosphate poisoning
Atropine
increases the speed of AV
conduction.

Magnesium is indicated 25-50 mg/kg IV/IO Magnesium produces

Magnesium for the treatment of over 10-20 min vasodilation and may
sulphate documented cause hypotension if
hypomagnesemia. administered rapidly
Increases force of IV/IO: 2-20
contraction and heart rate; mcg/kg/min infusion
Dobutamine causes mild peripheral -
dilation; may be used to
treat shock.
Increases force of IV/IO infusion: 2-
contraction and cardiac 20 mcg/kg/min
output, increases
Dopamine -
peripheral vascular
resistance, BP and cardiac
output.

Conclusion-