2.  Most Cases of cardiac arrest in children are
preceded by respiratory failure
 Most common form in children
 Heart stops due to ischemia or hypoxia
secondary to another condition
 Arrest rhythm is usually bardycardia
progressing to asystole
 Hypoxia initially present
 Out com depends on prevention or prompt
resuscitation

3. PATHWAY LEADING TO CARDIAC ARREST IN CHILDREN
RESPIRATORY
OBSTRUCTION
FLUID
LOSS
RESPIRATORY
DEPPREESION
FLUID
MALDITRUBITON
FABO
ASTHMA
CONVULSION
POISINING
RASIED ICP
BLOOD LOSS
BURNS
VOMITING
SEPSIS
ANAPHYLAXIS
CARDIAC
FAILURE
RESPIRATORY FAILURE CIRCULATORY FAILURE
CARDIAC ARREST

4. Primary survey
Resuscitation
Secondary survey
Emergency treatment
Continuing stabilization and definitive care

5.  An 18 month old girl is brought into the
A&E department by paramedics having
been found lying face down in the
neighbours outdoor swimming pool. Her
mother states that she had been missing
for 5 minutes. Basic life support has been
carried out on the pool side and during
transportation to hospital

6.  Initial Impression
 The child is pulseless and apnoeic. She
is very cold to touch

7. Cardiac Arrest
ABC
Check the pulse
Attach monitor/defibrillator
Shockable
Ventricular Fibrillation (VF) Ventricular
Tachycardia (VT)
NON Shockable
Asystole / Pulseless Electrical
Activity (PEA)

8. Ventricular Fibrillation
(VF)
No Pulse: Shockable

10. During CPR
Attempt /Verify Tracheal intubation
Intraosseous /Vascular access
Check Electrodes/Paddles position and contact
Give Adrenaline every 3 minutes
Consider antiarrhythmics
Consider giving Bicarbonate
Correct reversible causes ( 4H/4T)
Hypoxia Tension Pneumothorax
Hypovolaemia Tamponade
Hyper/hypokalaemia Toxic/therapeutic
Hypothermia Thromboemboli

11. Adrenaline
 IV / IO 10 mcg /kg
0.1 ml/kg of 1:10 000 solution
 ET 100 mcg/kg
0.1ml/kg of 1:1 000 solution
 May be repeated every 3 minutes

12.  Intubate to prevent aspiration
 Gastric drainage to remove
swallowed water
 Measure core temperature
and treat hypothermia
 Full trauma assessment for other injuries

13.  Blood glucose
 Arterial blood gases and lactate
 Urea, electrolytes and coagulation status
 Blood and sputum cultures
 Chest x–ray
 Lateral cervical spine x-ray or CT scan

14.  Hypothermia may be protective, continue
to resuscitate until expert advice obtained
 Active core rewarming vital
 Do not give initial medications until core >
30o C
 Give initial defibrillating shocks but do not
repeat until core >30o C
 Volume expansion may be needed

15. External rewarming
 Remove wet clothing
 Wrap warmly
 Radiant heat
 Warm air system
 Direct heat
Core rewarming
 IV fluids to 39oC
 Ventilator gases to
42oC
 Gastric/bladder/
peritoneal/pleural
lavage at 42o C
 Endovascular warming
 Extra-corporeal
rewarming with by-pass

16.  Airway
 Oral tracheal intubation

 Breathing
 Bag and mask with added O2

 Bag and ETT with added O2

 Circulation
 VF protocol

 General Therapy
 Uninterrupted BLS

 Specific Therapy
 Resus until T>32, active rewarming


17.  Diagnosis
 Cardio-respiratory arrest, ventricular
fibrillation, hypothermia secondary to
drowning

18. Intensive Care
Pre-Hospital
Surgery
Rapid ResponseEmergency Medicine
Medical
Center

19.  History

 A 3 year old girl was eating a sandwich when
she suddenly started coughing, and then
stopped breathing. Her mother picked her up
and slapped her back but couldn't dislodge
the food. She called an ambulance. On
arrival a paramedic performed abdominal
thrusts and dislodged piece of bread. Basic life
support was started.
 Initial Impression
 Apnoeic and pulseless

20.  Clinical Course}
 The child remains in asystole until
satisfactory ventilation is achieved, initial
drugs have been given and one cycle of
the asystole protocol has been
completed. She then develops sinus
tachycardia on the monitor but there is
no pulse

21.  She has PEA secondary to a tension
pneumothorax. This responds to chest
decompression. Guide weight 14kg

22. PEA no palpable pulses

23. PROTOCOL FOR ASYSTOLE AND PEA
2min CPR High flow O2, IV/IO access
ROSC
Oxygen should be titrated (spO2 94%-98%)
Therapeutic hypothermia
Blood glucose control
Parental presence
Drugs used in CPR
Adrenaline; induce vasoconstriction, increase coronary perfusion
Amiodarone; is a membrane –stabilising anti-arrhythmic drug, used in treatment of
shockable rhythms
Atropine; is effective in increasing HR when bradycardia is caused by excessive vagal tone
Sodium bicarbonate; the routine use of it is not recommended.
Calcium; administration of calcium during cardiac arrest has been associated with increased
mortality
Magnesium; is indicated with documented hypomagnesaemia or with polymorphic VT
Assess rhythm
Continues CPR
Post cardiac arrest treatment
If signs of life check rhythm if perfusable
rhythm, check pulse.
Adrenaline immediately and
then every 4minutes 1omcg/kg
IV or IO
Consider 4Hs and 4Ts

24. Proximal Humerus Proximal Humerus
Proximal Tibia Proximal Tibia
Distal Tibia Distal Tibia
Distal FemurDistal Femur
Intraosseous access sites for the pediatric patient
Site is most suitable for
patients
5 years of age and older
Site is suitable most for
patients
5 years of age and older

25.  Airway
 Establish airway patency

 Oral tracheal intubation
 Breathing
 Bag and mask with added O2
 Bag with TT with added O2
 Circulation
 IV/IO access
 Asystole protocol

 PEA protocol
 General Therapy
 Uninterrupted BLS
 Specific Therapy
 Needle Thoracocentesis

26.  History
 A 10 month old girl is brought into the
Emergency Department with a 12 hour
history of vomiting and diarrhoea
 Initial Impression Respiratory rate 36,
pulse 130, capillary refill 4 seconds.
Appears pale and hypotonic.

27.  Clinical
 The child continues to have vomiting and profuse
watery diarrhoea. Blood pressure is 90 systolic.
Following 20 ml/kg of normal saline the pulse rate
comes down to 115 per minute and the child
appears more alert. The child is started on
maintenance fluids but an hour later when she is
about to go to the ward and following further
vomiting and profuse diarrhoea she again has a
pulse rate of 140 and is pale and lethargic. A further
fluid bolus corrects this. The serum sodium taken on
insertion of the IV cannula is reported as 132 mmol/l

28.  Airway
 Establish airway patency
 Breathing
 Oxygen via face mask
 Circulation
 IV access
 Fluid bolus x 2
 General Therapy
 Calculation of maintenance fluids and electrolytes
 Diagnosis
 Gastroenteritis

29.  History
 A five day old infant is brought to A&E by
his parents. He was born at full term and
was born by a normal delivery. Initially
he was well, but over the last 24 hours he
has become increasingly lethargic and
has not fed for 8 hours

30.  High flow oxygen should be administered
and airway breathing and circulation
assessed. IV access is only possible via
the intraosseous route. Blood sugar
should be checked. The infant worsens
after the first bolus of fluid and femoral
pulses are still absent.


31.  Initial Impression
 He is pale and drowsy but responding to
pain. Respiratory rate is 75bpm, heart rate
195bpm and pulses are difficult to feel.
Capillary refill time is seven seconds
centrally.
 Additional History and Observations
 Mum was well through the delivery. There
are no risk factors for infection.

32. 
Cyanosis, not correcting with oxygen
therapy
 Tachycardia out of proportion to respiratory
difficulty
 Raised jugular venous pressure
 Gallop rhythm, murmur
 Enlarged heart on CXR
 Enlarged liver
 Absent femoral

33.  Neonates with ,duct-dependent
pulmonary circulation (e.g., critical
pulmonary
stenosis, pulmonary atresia, tricuspid
atresia)
 Neonates with duct-dependent systemic
circulation (eg transposition of great
arteries, .aortic stenosis, /Artesia,left
hypoplastic heart, coractation of aorta) .

34.  Give an intravenous infusion of Prostin
(e.g. for PGE2):
 Initial dose of 5 nanograms/kg/min (may
be increased. to 20 nanograms/kg/min
in 5-nanograms/kg /min increments until
side, effects develop
 Suggested preparation of PGE2 : Add 1ampule(500mcg) to
50 ml = 0.6ML/ h x weight kg needed to infuse 0.1
mcg/kg/min

35.  This is a duct dependant lesion and
requires treatment with an IV infusion of
alprostadil. This condition can be
difficult to differentiate from sepsis in the
neonate so if the candidate gives IV
antibiotics this should be accepted as
good practice. Guide weight 4kg

36.  Airway
 Airway opening manoeuvres

 Breathing
 High flow oxygen

 Plan for intubation

 Circulation
 IV access

 1 x fluid bolus

 Specific Therapy
 IV alprostadil

 Contact Cardiac centre


 Diagnosis
 Shock secondary to coarctation of the aorta

37.  History
 A four year old boy is brought to A&E by his
parents He has been unwell for twenty-four
hours with right-sided abdominal pain, and
over the last few hours he has had some bile
stained vomiting. His father tried to wake him
and give him a drink, but was unable to rouse
him.

Initial Impression
 Unrousable. Pale child. Shallow breathing.
Cold, mottled peripheries

38.  Additional History and Observations

 Respiratory rate 45 bpm, barely fogging the mask.
Capillary refill time is 7 seconds and heart rate 170
bpm. The abdomen is rigid on palpation.

 Clinical Course
 The child becomes bradycardic and apnoeic while
IV access is sought. Bag and Mask ventilation is
started, and if compressions are not started the child
develops PEA. The child improves after two boluses
of fluid. A surgical opinion should be sought. Guide
weight 16kg.


39.  while IV access is sought. Bag and Mask
ventilation is started, and if compressions
are not started the child develops PEA.
The child improves after two boluses of
fluid. A surgical opinion should be
sought. Guide weight 16kg.

40.  Airway
 Establish airway patency
 Breathing
 High flow oxygen
 Attempt bag-mask ventilation with O2

 Circulation
 Chest compression

 IV access

 Bradycardia protocol

 Fluid bolus x 2

 Specific Therapy
 IV Antibiotics

 Surgical opinion


 Diagnosis
 Septic shock secondary to perforated appendix


41. Diagnosis
 Septic shock secondary to perforated
appendix

42.  History
 A 3 year old boy is carried into Accident & Emergency in
his fathers arms. He is pale, limp and having difficulty
breathing. The father says he has been unwell and
coughing for 3 days.

 Initial Impression
 Respiratory rate is 60 with marked intercostal recession
and a tracheal tug. Pulse 150. He is thin, pale and only
responsive to painful stimulation.
 Additional History and Observations
 His temperature is 36oC. SaO2 is 76% in 100% O2 by face
mask. Capillary perfusion is 6 sec. BP 60/? and thready

43.  Clinical Course
 The child is peripherally shut down and
needs a bolus of fluids and IV antibiotics.
Despite high flow O2 saturation remains
poor as he is exhausted and needs
elective intubation. If this is not carried
out bradycardia develops prior to
asystole.. There is then gradual
improvement. Guide weight 14 kg.


44.  systemic inflammatory response syndrome(SIRS)
 the presence of at least two of the following four
criteria, one of which must be abnormal temperature or
leukocyte count:
 core [oral or rectal]temperature of>38.5C or <36C
 Tachycardia, in the absence of external stimulus , chronic
drugs, or painful stimuli, or otherwise unexplained
persistent elevated period or for children< 1 year old :
bradycardia , in absence of vagal stimulus , B-blocker
drugs, or congenital heart depression over a 0.5-h time
period
 Tachypnea for an acute process not related to underlying
neuromuscular disease.
 Leukocyte count elevated or depressed for age [ not
secondary to chemotherapy-induced leucopenia] or
>10% immature

45. EFFORT
EFFICACY
EFFECT

46.  Heart Rate; Tachycardia – bradycardia
 Skin colour: Pallor, mottling secondary to
endogenous epinephrine
 Mental Status :Agitation, restlessness, reduced
conscious level, coma

47.  Airway
 Establish airway patency

 Breathing
 High flow O2 via face mask

 Electively intubate & ventilate with 100% O2

 Circulation
 IV access

 Fluid bolus

 Specific Therapy
 IV antibiotics


 Diagnosis
 Severe bilateral pneumonia (probably streptococcus pneumoniae)

48.  Diagnosis
 Severe bilateral pneumonia (probably
streptococcus pneumoniae)

49.  History
 A five-year-old boy is brought into the A&E
department with vomiting and fever. The
parents describe these symptoms as having
developed during the morning and he now
doesn’t want to walk at all.

 Initial Impression
 Respiratory rate 25/min, SaO2 98%, heart
rate 95/min, capillary refill 2s, temperature
40.7ºC. Initially responds to voice

50.  Additional History and Observations

 He had been complaining of headache.
His blood pressure is 120/95 and he has
good pulses. He has small, poorly
reactive pupils. Exposure reveals some
petechia on his abdomen and lower
limbs.

51.  Clinical Course
 His conscious level deteriorates. He
requires airway control, assessment of
conscious level and posture,
management of raised intra-cranial
pressure and i.v. antibiotics. An
anaesthetic colleague may help with
intubation. Guide weight 18kg.


52. Conscious Level
Posture
Pupillary Signs

53.  Alert A
 Responds to Voice V
 Responds only to Pain P
 Unresponsive U

54.  . He requires airway control, assessment
of conscious level and
posture, management of raised intra-
cranial pressure and i.v. antibiotics. An
anaesthetic colleague may help with
intubation. Guide weight 18kg.

55.  Treatment of disability in shock
 The priority in patients with a mixed picture of shock and meningitis is
 brain perfusion is dependent on adequate cardiac output.
 If signs of raised ICP persist tracheal intubation and mechanical ventilation should
be initiated urgently.
 Monitor CO2 levels by capnography and blood gases, and keep in a normal
range
 Insert a urinary catheter early, and monitor urine output.
 Nurse the child with 20° head elevation and midline position.

 Lumbar puncture must be avoided as its performance may cause death through
coning of the brainstem through the foramen magnum.

56.  Airway
 Establish airway patency

 Insert oropharyngeal airway

 Breathing
 High flow O2

 Orotracheal intubation & ventilate with O2

 Circulation
 IV access

 Disability
 Head in-line and raised 20º

 Mannitol

 Specific Therapy
 IV cefotaxime / ceftriaxone

 IV dexamethasone



57.  Diagnosis
 Acute meningitis – raised intra-cranial
pressure