Hi. I’m Mark. Welcome to the first in our video series covering PALS (pediatric advanced life support). Today we’re going to review the cardiac arrest algorithm.
When it comes to PALS (pediatric advanced life support) and cardiac arrest in children, there’s kind of good news and bad news. The good news is that in America, in the field and in the ER, we don’t have to treat critically ill or injured children every day, which is a good thing. I have kids, you have kids, and nobody wants to see a busted up kid. The bad news is that every day across America, in the field and in the ER, we’re not treating critically ill or injured children, which means we don’t do it very often, which means we’re not always real great at it. Combine that with the emotional stress of treating a child, it makes dealing with a pediatric emergency very difficult. How do we manage that? How do we minimize, mitigate our messing up PALS? One, education, doing what we’re doing today. We’re going to review the algorithms. We’re going to talk about it.
In an emergency, one of your best friends when it comes to pediatric emergencies is the Broselow tape. Hands down—I’ve used it—a wonderful tool. How the Broselow tape works is you lay this tape out, starting from the head of the child to the foot. What Dr. Broselow did is he found a correlation between the length of the child and the weight of the child, because most of our interventions are weight-based in the pediatric patient. Start at the head. Lay the Broselow tape out. Where their feet wind up on the tape, it’ll give you the weight of the child—the rough, estimated weight of the child—and all the interventions. Your airway, tube size, blade size, IV size, your drug references, how much drug and what kind of drug—all those are calculated on the Broselow tape. In addition to the Broselow tape, I’ve been using a lot of pediatric apps for years on my smartphone. There are very handy. If I’m going to fly a kid, as soon as I know the weight I punch the kid into this application. Then I already know the drugs that I’m going to need and all the toys that I’m going to need to treat this kid. It’s all right there in the application. Find an app that you like. Become familiar with it, know how to use it, and use that. Minimize the stress, be prepared.
We know that the leading cause of cardiac arrest in a child is respiratory failure. Our goal in the cardiac arrest algorithm is prevention, avoidance. We do not want the child to get to this. We do not want to be in this algorithm. We can help minimize our travel of this algorithm by treating the respiratory component first. Let’s take a look at respiratory distress and respiratory failure and try to keep this kid out of this algorithm.
The average 4-year-old uses twice as much oxygen per minute as an adult does. He has a faster metabolism. Everything is sped up. He needs more oxygen. You look at a small kid, twice as much oxygen as an adult. An infant under the age of 1, three times as much. They’re chewing through oxygen. We have to constantly be aware of that. They are oxygen-dependent little creatures. They have little Ferrari metabolisms, and they’re fed on oxygen. Respiratory distress: This is a kid who’s tachypneic. They’re breathing fast. They’re compensating. They’re going to be positioning, tripoding. Use of accessory muscles—you’re going to see tugging in the neck, seesaw respirations. You want to be listening to this kid’s chest. They’re going to be tachycardic. Everything is sped up in respiratory distress. That’s where we need to jump on this kid and treat him aggressively. If you see a kid come into the ER in respiratory distress and you read the chart, the doctor gave him albuterol, steroids, antipyretics, antibiotics, a college scholarship. He’s throwing everything at this kid to keep him from going into respiratory failure. In respiratory failure, everything starts to slow down. The respiratory rate starts to slow down, altered level of consciousness—huge, this kid has petered out and he’s losing consciousness now. Bradycardia—the heart rate is going to start slowing down. Bradycardia in a child is an ominous sign. This is pre-arrest. This kid is about to arrest on you. In respiratory distress, remember, everything is speeding up. In respiratory failure, everything is starting to slow down. Let’s dive into this algorithm.
First, start CPR. Start your chest compressions. Next, the algorithm says give oxygen. How are you going to give this oxygen? Positive pressure ventilation with 100% oxygen, 100% FiO2. Remember, kids and small children have these huge, giant alien heads on the top of their necks. When they’re lying flat on their back, this large head puts their airway in deflection. It can really block off their airway. To perform effective bagging on a child, we have to position the airway. We need to get something behind those shoulders, raise the shoulders, allow for that huge melon on the top of their neck, so we can properly align their airway and perform positive pressure ventilations. What are we looking for when we ventilate? Chest rise, the same as an adult. The air should be going in and coming out. Next, get him on a monitor. Is this a shockable rhythm? Shock your patient. The dosing, the amount of energy we’re going to administer to our pediatric patient, the first shock, first defibrillation is 2 J/kg. Subsequent shocks are at 4 J/kg. If you think about it—and I try to make things easy—that 2 J/kg is the same as the patient’s weight in pounds, right, as 1 kg is 2.2 pounds. Instead of 2 J/kg—and I still think in American terms; I still think pounds, ounces, gallons; I’m not always thinking metric—if I look at this kid and I have a 25-pound kid, that’s my first shock, 25 J. The second shock is going to be twice that, 50 J. I tend to think pounds, double-pounds when it comes to defibrillating kids. Now, we’ve administered the shock. Immediately after we’ve defibrillated this patient, resume chest compressions. While we’re doing the chest compressions, we need to gain vascular access, either intravascular (IV) or IO access, which is very popular—drill that kid’s leg, gain vascular access. First drug up is epinephrine. Administer epinephrine as quickly as you can. Our dose is 0.01 mg/kg. That’s 0.01 mg/kg of 1:10,000 epinephrine. Where the rubber meets the road is you actually have to draw this up and give it to your patient. That 0.01 mg/kg equals 0.1 mL/kg administered. Rather than trying to calculate the dose and how much you’re going to draw up, if you’re using 1:10,000 epinephrine, which you should, that 0.01 mg/kg is the same as 0.1 mL/kg. Draw that up, administer it to your patient. Remember to apply a syringe flush of saline afterwards. We need to move that drug to the heart. We have to get that drug out of the periphery and get it to the heart so it can be effective. So far, we’ve gained vascular access and we’ve administered our epinephrine. We need to think about an advanced airway. One of the number one reasons that pediatric patients cardiac arrest is respiratory failure, so be thinking early about an advanced airway on your pediatric patient. You’re going to continue your chest compressions for 2 minutes, then reassess the rhythm. If it’s a shockable rhythm, you’re going to administer another defibrillation. However, this would be your second defibrillation, so you’re going to increase the amount of energy to 4 J/kg, or double-pounds. You gave the first shock, say they weighed 25 pounds, 25 J. Subsequent shock, double that, 50 J. Immediately after your second defibrillation, resume chest compressions. Any time you administer a defibrillation, immediately after you shock them, resume chest compressions. Our next drug up, we need to think about an antiarrhythmic. One of the new guideline changes this year has been between lidocaine and amiodarone—either is fine. In 2010, they preferred amiodarone over lidocaine. I’m a lidocaine guy, everybody knows that. With the new guideline changes, you can select either amiodarone or lidocaine. They’ve both been proven to be effective. For amiodarone, 5 mg/kg IV push followed by a flush to move that drug to the central circulation. If we’re using lidocaine, 1 mg/kg. Again, IV push followed with a flush to move that drug to the heart. Get it out of the periphery and get it to the heart so it can do something. After we’ve administered your antiarrhythmic, be thinking about a reversible cause. Is there a cause why this child cardiac arrested, and can we fix that? We need to assess for it, find it, and fix that reversible cause. If this is not a shockable rhythm, is it asystole or is it PEA (pulseless electrical activity), which is an organized rhythm on the monitor but the patient has no pulse? If this is the case, immediately begin chest compressions, gain vascular access—either peripheral IV (again, 2 attempts, 90 seconds is kind of the rule) or if not, go right to intraosseous infusion—and administer epinephrine immediately. The first drug for any pulseless rhythm is always epinephrine. After 2 minutes of chest compressions, reassess the rhythm. Are they now in a shockable rhythm? If they are, administer a defibrillation and move down that side of the algorithm. If they’re not, continue your chest compressions, continue your bagging, and, again, assess for reversible causes. If we do have a return of spontaneous circulation—we’ve shocked them, we’ve gotten our airway, we now have a breathing patient, and we have a pulse—we want to assess the blood pressure, maintain adequate oxygenation, maintain adequate blood pressure, which may require fluids or pressors, and then consider therapeutic hypothermia treatment. If this patient is not responsive and they’ve had a return of spontaneous circulation, think about cooling that patient. Next, where are we going to take this kid? We need to take this child to a facility that can appropriately treat a post cardiac arrest pediatric patient.
Remember, when looking at the pediatric cardiac arrest algorithm, it didn’t start here. There was stuff that came before this. Before the cardiac arrest, there was a respiratory arrest. Before the respiratory arrest, there was respiratory failure. Before the respiratory failure, there was respiratory distress. That’s when this algorithm really started.
We have to remember the stress that pediatric arrests can cause everyone involved with the case. Two of my students, last week, while doing their clinical rotations in the ER had their first pediatric arrest. A 2-month-old presented in asystole. They worked this child, and the child expired. As educators, instructors, senior staff, we have to remember that this can be very stressful, especially for the new people. When they came down to my office and they were telling me about this, I put everything away. We had to talk about this for a minute and start our stress debriefing. We started with the emotional aspect of it. How did it make you feel? Believe me, there wasn’t a dry eye in the ER after this case. This was a wonderful family, an unexpected death. This was the worst thing that could possibly happen. So first, there’s crying, there’s hugging, and we talk about it, what happened. Then, as an instructor, I had them go through step-by-step everything that was performed on this child. At one point, the student told me that toward the end of the arrest, the doctor opened up and said, “Does anybody have any other ideas?” which is appropriate. Did he miss something? Did we all miss something? Is there something else we could have done? Does anybody else have any ideas? What ideas was he looking for? The cause of the arrest, the H’s and the T’s. When we got done with the emotional aspect of reviewing this, we moved over to the clinical aspect. I had the students review all the H’s and T’s. What could have been the possible cause of this? In an event like this, the best thing we can do is learn from it and then take what we learned to our next pediatric patient, because there’s going to be one. Remember your critical stress debriefings, address the emotional aspect of the event and then look at the clinical aspect of it. What could we learn from it that we can take to our next patient?
Today we reviewed the pediatric cardiac arrest algorithm. I’m Mark. Thanks for watching. I will see you in the next video.