Paed CPR ppt

PAEDIATRIC CARDIOPULMONA

RY RESUSCITATION

Dr Dilan Ranasinghe Cardiothoracic unit NHSL

CARDIOPULMONARY RESUSCITATION

1. CPR is an important life saving first aid skill.

2. It is the only known effective method used to sustain ventilation & blood flow …...

Who has suffered cardiopulmonary arrest Long enough for definitive treatment to be

delivered.


History Mouth to mouth ventilation - 1946

James Elam – (During Polio outbreak) Chest compressions – 1960

Accidental discovery William Bennett Kouwenhoven, Guy knickerbocker &

James Jude. Studying defibrillation in dogs Forcefully applying the paddles to the chest of dogs

Pulse in Femoral artery

Defibrillation 1st successful internal Defibrillation – 1947

Prof. Claude Beck (Prof. of Surgery) External Defibrillator - 1955

Paul Zoll


CPR - 1954 James Elam & Peter Safar demonstrated

experimentally that CPR is a sound technique. Clearing airway Mouth to mouth breathing Chest Compressions

Peter Safar work further to popularize the procedure around the world.

He collaborated with Norwegian Toy maker Asmund Laerdal to create the CPR training mannequin “Resusci Anne”

PAEDIACTRIC CPR

One major difference between adult and paediactric Cardiopulmonary arrest is…..

Etiology Children usually develop cardiac arrest

secondary to…….. 1. Respiratory arrest2. Shock Syndrome

Children usually have very poor survival rates from cardiac arrest Because it is often associated with prolong

Hypoxia Shock

PAEDIACTRIC CPR

The best chance for a good out come is to

1. Recognize impending Resp. failure / Shock2. Intervene

The Priorities of Resuscitation arei. Airwayii. Oxygenationiii. Ventilationiv. Shock management

PAEDIACTRIC CPR

Anatomy of Paediactric Airway1. Much smaller than adult.2. Size varies by age.3. Airway is higher & more anterior.4. The tongue & Epiglottis are relatively larger.5. Infants < 6/12 are primarily Nasal breathers.6. Prominent Occiput causes flexion of the neck

on supine position.7. Overextension may kink the trachea

(Cartilaginous support poor)

Foreign body airway obstruction (FBAO)

1. When a foreign body enters the airway ► Reflex coughing in an attempt to expel it.

2. Spontaneous cough is more effective & safer than any other manoeuvre.

3. However, if coughing is 1. Absent or ineffective 2. Object completely obstructs the airway, ► the child will rapidly become asphyxiated.

4. Active interventions to relieve FBAO are therefore required.

5. Needed to be commence rapidly and confidently.


1. FBAO is characterised by the sudden onset of respiratory distress associated with

► coughing, gagging, or stridor.

2. Similar signs and symptoms can be seen ini. Laryngitis

ii. Epiglottitis

which require different management.

3. Suspect FBAO if: a. The onset was very sudden

b. There are no other signs of illness

c. History of eating or playing with small items


Chocking Child (Foreign Body Management)1. No blind finger sweeps2. Is the child conscious? Yes

The airway should be inspected for visible obstruction Only visible object is removed.

3. If the victim is a infant Alternating sequence of

Five back blows and Five chest thrusts

4. For older child Able to maintain some Ventilation / Vocalization

Coughing If fail

Back blows / thrusts

5. These are continues until the Obstruction is Cleared / Child become unconscious.


Is the Cough Effective?

Back blowsFor an infant1. Support the infant in a head-downwards, prone position, to

enable gravity to assist removal of the foreign body.

2. A seated or kneeling rescuer should be able to support the infant safely across his lap.

3. Support the infant’s head by placing the thumb of one hand at the angle of the lower jaw, and one or two fingers from the same hand at the same point on the other side of the jaw.

4. Do not compress the soft tissues under the infant’s jaw, as this will exacerbate the airway obstruction.

5. Deliver up to 5 sharp back blows with the heel of one hand in the middle of the back between the shoulder blades.

6. The aim is to relieve the obstruction with each blow rather than to give all 5.

Child over 1 year7. Back blows are more effective if the child is positioned head

down.

8. A small child may be placed across the rescuer’s lap as with an infant.

9. If this is not possible, support the child in a forward-leaning position and deliver the back blows from behind.

Chest thrusts for infants

1. Turn the infant into head downwards supine position.

This is achieved safely by placing your free arm along the infant’s back and encircling the occiput with your hand.

2. Support the infant down your arm, which is placed down (or across) your thigh.

3. Identify the landmark for chest compression

Lower sternum approximately a finger’s breadth above the xiphisternum

4. Deliver 5 chest thrusts. 1. These are similar to chest compressions

2. But sharper in nature and delivered at a slower rate.

Abdominal thrusts for children over 1 year

1. Stand or kneel behind the child.

2. Place your arms under the child’s arms and encircle his torso.

3. Clench your fist and place it between the umbilicus and xiphisternum.

4. Grasp this hand with your other hand and pull sharply inwards and upwards.

5. Repeat up to 5 times.Ensure that pressure is not applied to

the xiphoid process or the lower rib cage

This may cause abdominal trauma.

Reassess the child following chest or abdominal thrusts

1. If the object has not been expelled and the victim is still conscious,

1. Continue the sequence of back blows and thrusts.

2. Call out, or send, for help if it is still not available.

3. Do not leave the child at this stage.

2. If the object is expelled successfully, assess the child’s clinical condition.

1. It is possible that part of the object may remain in the respiratory tract and cause complications.

3. Abdominal thrusts may cause internal injuries 1. All victims so treated should be examined by a medical

practitioner.

PAEDIACTRIC CPR

Unconscious Child 1. First attempt should be ventilation

Airway should be inspected for visible obstruction.

No blind finger sweeps.

2. Until equipments are ready BLS should be commenced.

Age definitions An infant is a child under 1 year. A child is between 1 year and puberty

Paediatric Basic Life SupportUnresponsive?

Shout for Help

Open airway

NOT BREATHING NORMALY?

5 Rescue Breaths

STILL UNRESPONSIVE?

(No signs of circulation?)

15 Chest Compressions2 Rescue Breaths

Check the child’s responsiveness1. Ensure the safety of rescuer and child.

2. Gently stimulate the child and ask loudly, ‘Are you all right?’

3. Do not shake infants/children with suspected cervical spine injuries.

4. If the child responds by answering or moving:1. Leave the child in the position in which you find him

comfortable and out of danger.

2. Check his condition and get help if needed.

3. Reassess him regularly.

5. If the child does not respond:Shout for help

Opening the Airway1. Open the child’s airway by tilting

the head and lifting the chin:1. Easier if the child is turned to supine

position

2. Place your hand on his forehead and gently tilt his head back.

3. At the same time, with your fingertip(s) under the point of the child’s chin, lift the chin.

4. Do not push on the soft tissues under the chin as this may block the airway.

2. If you still have difficulty in opening the airway, try the jaw thrust method:

1. place the first two fingers of each hand behind each side of the child’s mandible (jaw bone) and push the jaw forward.

Is the child breathing?

1. KEEPING THE AIRWAY OPEN

1. Look for chest movements.

2. Listen at the child’s nose and mouth for breath sounds.

3. Feel for air movement on your cheek.

2. NO MORE THAN 10 SEC BEFORE DECIDING THAT BREATHING IS ABSENT.

IF THE CHILD IS BREATHING NORMALLY:

Turn the child onto his side into the recovery position

Check for continued breathing

IF THE CHILD IS NOT BREATHING/AGONAL GASPS

1. Carefully remove any obvious airway obstruction.

2. Give 5 initial rescue breaths.

3. While performing the rescue breaths note any gag or cough response to your action.

Rescue breaths for a child >1yr

1. Ensure head tilt and chin lift.2. Pinch the soft part of his nose closed with the

index finger and thumb of your hand on his forehead.

3. Open his mouth a little, but maintain the chin upwards.

4. Take a breath and place your lips around his mouth, making sure that you have a good seal.

5. Blow steadily into his mouth over about 1-1.5 sec watching for chest rise.

6. Maintaining head tilt and chin lift, take your mouth away from the victim and watch for his chest to fall as air comes out.

7. Take another breath and repeat this sequence 5 times.

8. Identify effectiveness by seeing that the child’s chest has risen and fallen in a similar fashion to the movement produced by a normal breath.

Rescue breaths for an infant

1. Ensure a neutral position of the head and apply chin lift.

2. Take a breath and cover the mouth and nasal apertures of the infant with your mouth

make sure you have a good seal.

3. Blow steadily into the infant’s mouth and nose over 1-1.5 sec sufficient to make the chest visibly rise.

4. Maintain head tilt and chin lift, take your mouth away from the victim, and watch for his chest to fall as air comes out.

5. Take another breath and repeat this sequence 5 times.

If you have difficulty achieving an effective breath

The airway may be obstructed:1. Open the child’s mouth and remove any visible

obstruction.

2. Do not perform a blind finger sweep.

3. Ensure that there is adequate head tilt and chin lift

4. Also that the neck is not over extended.

5. If head tilt and chin lift has not opened the airway, try the jaw thrust method.

6. Make up to 5 attempts to achieve effective breaths.

7. If still unsuccessful, move on to chest compression.

signs of a circulation (signs of life)

Take no more than 10 sec to:

1. Look for signs of a circulation.1. Any movement

2. Coughing

3. Normal breathing (not agonal gasps)

2. Check the pulse1. In a child over 1 year — feel for the carotid pulse in the neck.

2. In an infant — feel for the brachial pulse on the inner aspect of the upper arm

3. If there are no signs of a circulation,1. No pulse,

2. Slow pulse (less than 60 min-1 with poor perfusion),

3. You are not sure:

4. Start chest compression.

5. Combine rescue breathing and chest compression

Chest Compressions1. For all children, compress the lower third of the

sternum2. Depress the sternum approximately one-third of the

depth of the chest.3. Release the pressure4. Repeat compressions at a rate of about 100/min-1.5. After 15 compressions

1. Tilt the head, lift the chin

2. Give two effective breaths.

6. Continue compressions and breaths in a ratio of 15:2.7. Lone rescuers may use a ratio of 30:2.8. compression varies slightly between infants and

children.

Chest compression in infants1. The lone rescuer should compress

the sternum with the tips of two fingers.

2. If there are two or more rescuers, use the encircling technique

1. Place both thumbs flat, side by side, on the lower third of the sternum, with the tips pointing towards the infant’s head.

2. Spread the rest of both hands, with the fingers together, to encircle the lower part of the infant’s rib cage with the tips of the fingers supporting the infant’s back.

3. Press down on the lower sternum with your two thumbs to depress it approximately one-third of the depth of the infant’s chest.

Chest compression in children > 1 yr1. Place the heel of one hand over the lower third

of the sternum 2. Lift the fingers to ensure that pressure is not

applied over the child’s ribs.3. Position yourself vertically above the victim’s

chest and, with your arm straight, 4. Compress the sternum to depress it by

approximately one third of the depth of the chest.

5. In larger children → both hands with the fingers interlocked.

Continue resuscitation until:6. The child shows signs of life.

spontaneous respiration, pulse, movement

7. Further qualified help arrives.8. You become exhausted.

Paediatric Advanced Life Support

Sequence of Actions

Establish basic life support. Oxygenate, ventilate, and

start chest compression: As soon as possible the

child should be intubated. This will both control the

airway and enable chest compression to be given continuously

Thus improving coronary perfusion pressure.

Use a compression rate of 100 min-1.

Ventilation rate ꞊10/min-3.

Attach a defibrillator or monitor: Assess and monitor the cardiac rhythm.

Pads or paddles for

Children - 8 - 12 cm Infants - 4.5 cm

In infants and small children it may be best to apply the pads or paddles to the front and back of the chest.

Assess the rhythm on the monitor

1. Non-shockable (asystole or

pulseless electrical activity)

2. Shockable (VF/VT).

Drugs used in CPRAdrenaline IV/IO dose of adrenaline in children is 10 microgram kg-1. The dose of adrenaline via the tracheal tube route 100 microgram kg-1). Should be given every 3-5 min.

Amiodarone IV dose of amiodarone 5 mg kg-1, diluted in 5% dextrose, should be considered if VF or pulseless VT persists after a third shock

Atropine When bradycardia is unresponsive to improved ventilation and circulatory support, atropine may be used. The dose of atropine is 20 microgram kg-1, maximum dose of 600 microgram, and a minimum dose of 100 microgram to avoid a paradoxical effect at low

doses.

Magnesium Give magnesium sulphate by intravascular infusion over several minutes, dose of 25 - 50 mg kg-1 (to a maximum of 2 g).

Calcium calcium chloride is 0.2 ml kg-1 of the 10% solution. Calcium can slow the heart rate and precipitate arrhythmias

Newborn life support

1. Passage through the birth canal is a hypoxic experience for the fetus,

Sincesignificant respiratory exchange at the placenta is prevented for the 50-75 sec duration of the average contraction.

2. Though most babies tolerate this well, the few that do not They may require help to establish normal breathing at delivery.

3. Newborn life support (NLS) is intended to provide this help and comprises the following elements:

1. drying and covering the newborn baby to conserve heat;

2. assessing the need for any intervention;

3. opening the airway;

4. lung aeration;

5. rescue breathing;

6. chest compression;

7. administration of drugs (rarely).

Paed CPR ppt

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