Pediatric & Pediatric & Neonatal Neonatal

ResuscitationResuscitationDr. Mohammad MireskandariDr. Mohammad Mireskandari

Assistant professorAssistant professor

Bahrami Children’s HospitalBahrami Children’s Hospital

Pediatric Chain of SurvivalPediatric Chain of Survival For best survival and quality of life, pediatric basic life For best survival and quality of life, pediatric basic life

support (BLS) should be part of a community effort that support (BLS) should be part of a community effort that includes prevention, basic CPR, prompt access to the includes prevention, basic CPR, prompt access to the

emergency medical services (EMS) system, and prompt emergency medical services (EMS) system, and prompt pediatric advanced life support (PALS). These 4 links pediatric advanced life support (PALS). These 4 links form the American Heart Association (AHA) pediatric form the American Heart Association (AHA) pediatric

Chain of SurvivalChain of Survival

• Rapid and effective bystander CPR is Rapid and effective bystander CPR is associated with successful return of associated with successful return of spontaneous circulation and neurologically spontaneous circulation and neurologically intact survival in children.intact survival in children.

• The greatest impact occurs in respiratory The greatest impact occurs in respiratory arrest, in which neurologically intact arrest, in which neurologically intact survival rates of 70% are possible, and in survival rates of 70% are possible, and in ventricular fibrillation (VF), in which ventricular fibrillation (VF), in which survival rates of 30% have been survival rates of 30% have been documented.documented.

• Only 2% to 10% of all children who develop Only 2% to 10% of all children who develop out-of hospital cardiac arrest survive, and out-of hospital cardiac arrest survive, and most are neurologically devastated.most are neurologically devastated.

• The major causes of death in infants The major causes of death in infants and children are respiratory failure, and children are respiratory failure, sudden infant death syndrome sudden infant death syndrome (SIDS), sepsis, neurologic diseases, (SIDS), sepsis, neurologic diseases, and injuries.and injuries.

Sudden Infant Death SyndromeSudden Infant Death Syndrome

• SIDS is “the sudden death of an infant under 1 SIDS is “the sudden death of an infant under 1 year of age, which remains unexplained after a year of age, which remains unexplained after a thorough case investigation, including thorough case investigation, including performance of a complete autopsy, examination performance of a complete autopsy, examination of the death scene, and review of the clinical of the death scene, and review of the clinical history.history.

• The peak incidence of SIDs occurs in infants 2 to The peak incidence of SIDs occurs in infants 2 to 4 months age. 4 months age.

• The etiology of SIDS remains unknown.The etiology of SIDS remains unknown.• Risk factors include prone sleeping position, Risk factors include prone sleeping position,

sleeping on a soft surface, and second-hand sleeping on a soft surface, and second-hand smoke.smoke.

The BLS Sequence for Infants and The BLS Sequence for Infants and ChildrenChildren

Foreign-Body Airway Obstruction Foreign-Body Airway Obstruction (Choking)(Choking)

• More than 90% of deaths from foreign-More than 90% of deaths from foreign-body aspiration occur in children < 5 body aspiration occur in children < 5 years of age; 65% of the victims are years of age; 65% of the victims are infants.infants.

• Liquids are the most common cause of Liquids are the most common cause of choking in infants, whereas balloons, choking in infants, whereas balloons, small objects, and foods ( eg, hot dogs, small objects, and foods ( eg, hot dogs, round candies, nuts, and grapes) are the round candies, nuts, and grapes) are the most common causes of foreign-body most common causes of foreign-body airway obstruction (FBAO) in childrenairway obstruction (FBAO) in children

• Safety of Rescuer and VictimSafety of Rescuer and Victim• Check for ResponseCheck for Response• Activate the EMS System and Get the AEDActivate the EMS System and Get the AED• Position the VictimPosition the Victim• Open the Airway and Check BreathingOpen the Airway and Check Breathing• Give Rescue BreathsGive Rescue Breaths• Pulse Check (for Healthcare Providers)Pulse Check (for Healthcare Providers)• Rescue Breathing Without Chest Rescue Breathing Without Chest

Compressions (for Healthcare Providers Compressions (for Healthcare Providers Only)Only)

• Chest CompressionsChest Compressions

Pediatric Advanced Life Pediatric Advanced Life SupportSupport

• In contrast to adults, sudden cardiac In contrast to adults, sudden cardiac arrest in children is uncommon, and arrest in children is uncommon, and cardiac arrest does not usually result cardiac arrest does not usually result from a primary cardiac cause.from a primary cardiac cause.

• More often it is the terminal event of More often it is the terminal event of progressive respiratory failure or progressive respiratory failure or shock, also called an asphyxial shock, also called an asphyxial arrest.arrest.

• VF occurs in 5% to 15% of all pediatric victims of out-of hospital cardiac arrest and is reported in up to 20% of pediatric in-hospital arrests at some point during the resuscitation.

• The incidence increases with age.• Defibrillation is the definitive treatment

for VF with an overall survival rate of 17% to 20%

Medications to Maintain Cardiac Medications to Maintain Cardiac Output and for Postresuscitation Output and for Postresuscitation StabilizationStabilization

• Inamrinone 0.75–1 mg/kg IV/IO over 5 minutes; may repeat 2; Inamrinone 0.75–1 mg/kg IV/IO over 5 minutes; may repeat 2;

then: 2–20 g/kg per minute ,Inodilatorthen: 2–20 g/kg per minute ,Inodilator

• Dobutamine 2–20 g/kg per minute IV/IO Inotrope; vasodilatorDobutamine 2–20 g/kg per minute IV/IO Inotrope; vasodilator

• Dopamine 2–20 g/kg per minute IV/IO Inotrope; chronotrope; renal Dopamine 2–20 g/kg per minute IV/IO Inotrope; chronotrope; renal and splanchnic vasodilator in low doses; pressor in high dosesand splanchnic vasodilator in low doses; pressor in high doses

• Epinephrine 0.1–1 g/kg per minute IV/IO Inotrope; chronotrope; Epinephrine 0.1–1 g/kg per minute IV/IO Inotrope; chronotrope; vasodilator in low doses; pressor in higher dosesvasodilator in low doses; pressor in higher doses

• Milrinone 50–75 g/kg IV/IO over 10–60 min then 0.5–0.75 g/kg per Milrinone 50–75 g/kg IV/IO over 10–60 min then 0.5–0.75 g/kg per minute ,Inodilatorminute ,Inodilator

• Norepinephrine 0.1–2 g/kg per minute Inotrope; vasopressorNorepinephrine 0.1–2 g/kg per minute Inotrope; vasopressor

• Sodium nitroprusside 1–8 g/kg per minute Vasodilator; prepare Sodium nitroprusside 1–8 g/kg per minute Vasodilator; prepare only in D5W IV indicates intravenous; and IO, intraosseous.only in D5W IV indicates intravenous; and IO, intraosseous.

NeonatalNeonatalResuscitation GuidelinesResuscitation Guidelines

• Approximately 10% of newborns require some assistance to begin breathing at birth.

• About 1% require extensive resuscitative measures

• Those newly born infants who do not require resuscitation

can generally be identified by a rapid assessment of the

following 4 characteristics: ● Was the baby born after a full-term gestation? ● Is the amniotic fluid clear of meconium and

evidence of infection? ● Is the baby breathing or crying? ● Does the baby have good muscle tone?• If the answer to all 4 of these questions is “yes,” the

baby does not need resuscitation and should not be

separated from the mother.

• If the answer to any of these assessment questions is “no,” there is general agreement that the infant should receive one or more of the following 4 categories of action in sequence: A. Initial steps in stabilization (provide warmth, position, clear airway, dry, stimulate, reposition) B. Ventilation C. Chest compressions D. Administration of epinephrine and/or volume expansion

• The decision to progress from one category to the next is determined by the simultaneous assessment of 3 vital signs: respirations, heart rate, and color. Approximately 30 seconds is allotted to complete each step, reevaluate, and decide whether to progress to the next step.

Endotracheal Tube Placement

• Endotracheal intubation may be indicated at several points during neonatal resuscitation:

● When tracheal suctioning for meconium is required ● If bag-mask ventilation is ineffective or prolonged ● When chest compressions are performed ● When endotracheal administration of medications is

desired ● For special resuscitation circumstances, such as

congenital diaphragmatic hernia or extremely low birth weight

(1000 g)

Discontinuing Resuscitative Efforts

• Infants without signs of life (no heart beat and no respiratory effort) after 10 minutes of resuscitation show either a high mortality or severe neurodevelopmental disability .

• After 10 minutes of continuous and adequate resuscitative efforts, discontinuation of resuscitation may be justified if there are no signs of life.