Tuesday, January 31, 2012

Pediatric Advance Life Support: Unstable Bradycardia


Stable patient
·         Observe
·         Support ABCs
·         Reassess patient for symptoms of cardiac compromise

Note:  Reassess the patient to determine if bradycardia is still causing cardiorespiratory symptoms despite support of adequate oxygenation and ventilation

Unstable patient
·         Perform chest compression
·         Heart rate < 60/min in infant or child with poor systemic perfusion despite oxygenation

Note:  Revaluate the patient for signs of compromised cardiac output, including reduced responsiveness, weak central pulses, weak or absent peripheral pulses, hypotension, delayed capillary refill, and cool extremities.

Drug Management
·         Epinephrine
·         Atropine
·         Dopamine
·         Transcutaneous pacing

Drug Therapy
·         If ventilations and oxygen fail to correct bradycardia, consider drug therapy
·         Epinephrine 0.01mg/kg (0.1ml/kg of a 1:10,000 solution) IV or IO q3-5minutes
·         Epinephrine 0.1mg/kg (0.1ml of a 1:1000 solution) via ET tube q3-5minutes
·         Continuous infusion 0.1-0.3ug/kg titrate for effect for persistent bradycardia

Drug Therapy
·         Atropine 0.02mg/kg with minimum dose of 0.1mg IV or IO
·         Maximum single dose of 0.5mg for a child and 1mg for an adolescent
·         May repeat in 5 minutes to maximum cumulative dose of 1mg in child and 2mg in an adolescent
·         0.04-.06mg/kg via ET tube

Note:  Atropine sulfate is a parasympatholytic drug that accelerates sinus or atrial pacemakers and increases the speed of AV conduction.
If bradycardia is known or strongly suspected to be caused by increased vagal tone or primary AV heart block, administer atropine preferentially after establishment of oxygenations and ventilation

Atropine Indications
·         Increased vagal tone
·         Cholinergic drug toxicity- organophosphates
·         Complete heart block
·         Congenital heart problems

Drug therapy
·         Dopamine may be added for BP support
·         Dose range 2-20ug/kg/min
·         May cause tachycardia at high doses

Monday, January 30, 2012

Pediatric Advance Life Support: Unstable Bradycardia


Primary Causes
·         Heart blocks (congenital heart disease)
·         Heart transplants (vagal denervation)
·         Cardiomyopathies
·         Myocarditis
·         Surgical injury to pacemaker or conduction system

Secondary Causes
·         Hypoxemia
·         Hypothermia
·         Hypothermia
·         Head injury
·         Acidosis
·         Toxins- Digoxin, Beta Blockers, Calcium channel blockers
·         May be induced by excessive vagal stimulation from suctioning or intubation

Management
·         Most clinically significant bradydysrhythmias are caused by hypoxemia
·         Treatment aimed at airway support, ventilation and oxygenation
·         CPR is indicated for heart rates less than 60 and accompanied by hypotension

Note:  Because unstable bradycardia usually arises secondary to a respiratory problem, the initial goal is to secure the airway and establish adequate oxygenation and ventilation. Initiate bag-mask ventilation with high-concentration oxygen, and then reassess the patient’s heart rate and perfusion. If bradycardia and poor perfusion persist, provide chest compressions until the heart rate exceeds 60 beats per minute. If necessary, perform endotracheal intubation

Primary Survey
·         Airway:  Support airway
·         Breathing:  give 02, assist with bag mouth ventilation, attach pulse oximeter
·         Circulation:  Monitor BP, attach defibrillator/monitor, Establish IV/IO access, 12 lead EKG, labs

Note: Initiate bag-mask ventilation with high-concentration oxygen, then reassess the patient’s heart rate and perfusion. If bradycardia and poor perfusion persist, provide chest compressions until the heart rate exceeds 60 beats per minute.

Assess for cardiopulmonary compromise
·         Hypotension
·         Respiratory compromise
·         Shock with hypotension
·         Altered mental status
·         Sudden collapse
·         Cold, clammy skin
·         Delayed capillary refill
·         Absent or weak pulses

Note:  A child with unstable bradycardia usually demonstrates ineffective respiration marked by slow, irregular breathing and poor perfusion. Evaluate the patient for signs of compromised cardiac output, including reduced responsiveness, weak central pulses, weak or absent peripheral pulses, hypotension, delayed capillary refill, and cool extremities. A focused history and physical examination may identify potential causes, such as respiratory problems, fever or significant fluid loss.

Sunday, January 29, 2012

Pediatric Advance Life Support: Unstable Bradycardia


Bradyarrhythmia
·         Heart rate less than 60
·         Significant when accompanied by hypotension
·         Most common pre-arrest arrhythmia in pediatric patients
·         Often associated with hypoxemia, hypotension, and acidosis

Note:  Bradycardia, which is defined by a heart rate slower than 60 beats per minute, usually arises secondary to hypoxemia from airway compromise or ineffective respiration. The rhythm is usually sinus or junctional, but AV block may arise in the terminal phase.

Slow Rhythms

·         Heart Blocks
·         Bradycardia
·         Sinus Node arrest
·         Slow Junctional
·         Ventricular escape rhythms

Third Degree Heart Block

2nd Degree Heart Block Type II


Sinus Bradycardia

Sinus Arrest

Junctional Rhythm


Symptomatic Bradycardia
·         Symptomatic implies that an arrhythmia is causing symptoms, such as palpitations, lightheadedness, or dyspnea, but the patient is stable and not in imminent danger.
·         In such cases more time is available to decide on the most appropriate intervention

Unstable Bradycardia
·         Refers to a condition in which vital organ function is acutely impaired or cardiac arrest is ongoing or imminent.
·         When an arrhythmia causes a patient to be unstable, immediate intervention is indicated

Signs of Instability
·         Shock with hypotension
·         Altered mental status
·         Sudden collapse
·         Cold, clammy skin
·         Delayed capillary refill
·         Absent or weak pulses

Signs of End Organ Hypoprofusion
·         Depressed mental status
·         Decreased urine output
·         Metabolic acidosis
·         Tachypnea
·         Weak central pulses
·         Deterioration in color (eg, mottling, pallor, peripheral cyanosis)

Systolic Hypotension
● ˂60 mm Hg in term neonates (0 to 28 days)
● ˂70 mm Hg in infants (1 month to 12 months)
●˂70 mm Hg + (2 x age in years) in children 1 to 10 years
●˂90 mm Hg in children 10 years of age

Saturday, January 28, 2012

EKG Rhythm Strips 26: Ectopic beats

1.

2.

3.

4.

5.

6.

7.

Answers
1.
Sinus arrhythmia and a PAC








Sinus arrhythmia and a PAC.   The rhythm  irregular even with the PAC. The rate is between 46 -54.  There is an upright P wave before each QRS complex. PRI: .20 sec. QRS: .08  QT: .52.  The P wave of the PAC (4th complex) is buried in the T wave of the preceding complex.  You will notice that it differs in shape and height from the other T waves of the other sinus beats.  

2.
Atrial bigeminy







Atrial bigeminy.  The rhythm is regular except for the atrial ectopy.    The rate is 80.  There is an upright P wave for each QRS complex.  PRI: .12 sec.  QRS: .08 sec QT: .36   There are PACs every other beat which gives this a bigeminal pattern.  The P waves of the PACs are smaller than the native, sinus, P waves.  

3.
Atrial fibrillation with multifocal PVCs
Atrial fibrillation with multifocal PVCs.  The rhythm is irregular.   There are  fibrillatory waves but there are no readily identifiable P waves associated with each QRS complex.  The rate is controlled and about 60 (by counting the QRS complexes in a six second strip)  There is no PR interval. QRS: .06  QT: .42.  The  2nd and 7th complexes are multifocal PVCs.  This simply means that they arise from different foci within the ventricle. 


4.
Atrial fibrillation with slow ventricular response and a couplet of PVCs
Atrial fibrillation with slow ventricular response and a couplet of PVCs.   The rhythm is irregular.  The rate is in the 50s.  There are fibrillatory waves present but no P waves associated with each QRS complex.  PRI: none  QRS: .06  QT .40  The 4th and 5th complexes form a couplet or two PVCs that occur  one after the other.   The PVCs have different a different morphology so they are called multiform or multifocal PVCs.     The term slow ventricular response refers to the ventricular rate.   If the ventricular rate is < 60 then it is termed a slow response,  60-100 controlled rate, > 100 rapid ventricular response.  


5.
Sinus bradycardia with a PAC
Sinus bradycardia with a PAC.   The rhythm regular except for the PAC. The rate is 50.  There is an upright P wave before each QRS complex.  PRI: .20 sec. QRS: .08  QT: .52.  The P wave of the PAC (2nd complex) is buried in the T wave of the preceding complex.  You will notice that it differs in shape and height from the other T waves of the other sinus beats.  


6.
Sinus rhythm with unifocal PVCs
Sinus rhythm with unifocal PVCs.   The rhythm is regular except for the PVCs.   The rate is 100.   There are upright P waves before each sinus QRS complex.   PRI; .20 sec   QRS:  .12 sec   QT:  .28.   There are unifocal PVCs occurring every 5th beat, pentageminy. 


7.
First degree block with unifocal PVCs
1st degree AV block with unifocal PVCs.   The rhythm is regular except for the PVCs.   The rate is 78.   There are upright P waves before each sinus QRS complex.   PRI; .24 sec   QRS:  .08 sec   QT:  .40.   There are unifocal PVCs occurring every 6th beat, hexageminy perhaps. 



Reviewed 3/2/16

Pediatric Pulseless Ventricular Tachycardia (VT) and Ventricular Fibrillation (VF)

Magnesium
·         25-50mg/kg IV/IO
·         Maximum 2gm
·         Torsades de Pointes VT
·         Hypomagnesemia
·         Continue CPR for 2 minutes then defibrillate at 4J/kg

Note:  Magnesium is indicated for the treatment of documented hypomagnesemia or for torsades de pointes (polymorphic VT associated with long QT interval). Magnesium produces vasodilation and may cause hypotension if administered rapidly.

Sodium Bicarbonate
·         Dose 1mEq/kg IV/IO
·         For prolonged arrest interval
·         Hyperkalemia
·         Tricyclic antidepressant overdose

Note:  Routine use of sodium bicarbonate during pulseless arrest is not recommended. After you have provided effective ventilation and chest compressions and administered epinephrine, you may consider sodium bicarbonate for prolonged cardiac arrest

Termination of Resuscitative Efforts
·         No reliable predictors of outcome to guide when to terminate resuscitative efforts in children
·         Witnessed collapse, bystander CPR, and a short interval from collapse to arrival of professionals improve the chances of a successful resuscitation

Post-resuscitation
·         Maintain normal ventilation
·         Monitor temperature
·         Manage post-ischemic myocardial dysfunction
·         Maintain normal glucose

Ethical concerns
Family presence during resuscitation
Designated staff member should be available to support and remain with family during resuscitation
Positive psychological effects    
Planning, staff acceptance

Sources
PALS Provider Manual. American Heart Association 7272 Greenville Ave. Dallas, Tx 75231
Kleinman ME, Chameides L, Schexnayder SM, Samson RA, Hazinski MF, Atkins DL, Berg MD, de Caen AR, Fink EL, Freid EB, Hickey RW, Marino BS, Nadkarni VM, Proctor LT, Qureshi FA, Sartorelli K, Topjian A, van der Jagt EW, Zaritsky AL. Part 14: pediatric advanced life support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2010;122(suppl 3):S876–S908.

Friday, January 27, 2012

Pediatric Pulseless Ventricular Tachycardia (VT) and Ventricular Fibrillation (VF)


Epinephrine
·         Epinephrine 0.01mg/kg (0.1ml/kg of a 1:10,100 solution) IV or IO
·         Epinephrine 0.1mg/kg (0.1ml/kg of a 1:1000 solution) via ET tube
·         May repeat dose every 3-5 minutes
·         After 5 cycles of CPR then defibrillate at 4J/kg

Note:  Vasopressin, which is frequently useful in adults, is not recommended for children experiencing ventricular fibrillation or pulseless ventricular tachycardia

Drug Therapy: Epinephrine
·         Increases systemic vascular resistance
·         Increases aortic root pressure
·         Increases coronary and cerebral perfusion during CPR
·         Escalating or high doses without demonstrable benefit

Sequence
·         Epinephrine should be administered during chest compressions
·         Prior to rhythm check, prepare to recharge the defibrillator (4 J/kg or more with a maximum dose not to exceed 10 J/kg or the adultdose, whichever is lower)
·         Check the rhythm
·         If the rhythm is “shockable,” deliver another shock

Defibrillation 2nd shock



Drug Therapy: Antiarrhythmics
·         Amiodarone
·         Lidocaine

Note:  When VF/pulseless VT persists after 2 to 3 shocks plus CPR and administration of a vasopressor, consider administering an antiarrhythmic such as Amiodarone.  If Amiodarone is unavailable, Lidocaine may be considered. Consider magnesium for torsades de pointes associated with a long QT interval. You should administer the drug during CPR, as soon as possible after rhythm analysis


Amiodarone
·         Dose: 5mg/kg rapid IV/IO
·         Repeat doses q5 min up to 15mg/kg
·         May produce vasodilation and hypotension
·         Continue CPR for 2 minutes then defibrillate at 4J/kg or more with a maximum dose not to exceed 10 J/kg or the adult dose, whichever is lower)

Note:  Amiodarone slows AV conduction, prolongs the AV refractory period and QT interval, and slows ventricular conduction (widens the QRS).


Defibrillation 3rd shock








Lidocaine
·         Dose 1mg/kg rapid IV/IO bolus
·         May be given via ET tube
·         Continue CPR for 2 minutes then defibrillate at 4J/kg
·         May be repeated 0.5-1.0 mg/kg 15 minutes after the initial dose
·         Total maximum dose of lidocaine is 3.0 mg/kg
·         Continue CPR for 2 minutes then defibrillate at 4J/kg or more with a maximum dose not to exceed 10 J/kg or the adult dose, whichever is lower)

Note:  If vascular access is not available and the child has been intubated, administer lidocaine through the tracheal tube at 2 to 3 times the intravenous dose, diluted with normal saline to a volume of 3 to 5 mL

Sequence
·         The antiarrhythmic should be administered during chest compressions
·         Prior to rhythm check, prepare to recharge the defibrillator (4 J/kg or more with a maximum dose not to exceed 10 J/kg or the adult dose, whichever is lower)
·         Check the rhythm
·         If the rhythm is “shockable,” deliver another shock

Note:  If defibrillation is successful but VF recurs, resume CPR and give another bolus of amiodarone before trying to defibrillate with the previously successful shock dose

Defibrillation 4th shock

Thursday, January 26, 2012

Pediatric Pulseless Ventricular Tachycardia (VT) and Ventricular Fibrillation (VF)


Broweslow Tape



















Medication Dose Calculation
·         Use the child’s weight if it is known
·         If the child’s weight is unknown, it is reasonable to use a body length tape
·         No data regarding the safety or efficacy of adjusting the doses for obese patients

IV Access
·         Peripheral IV
·         Central line
·         Intraossious
·         Intratracheal


Note:  Limit the time you spend trying to obtain IV access.  If IV access cannot be achieved immediately then establish IO access.  If this is not possible then administer medications via the intratracheal route.


Intraosseous (IO) Access
·         All intravenous medications can be administered intraosseously
·         Onset of action and drug levels are comparable to venous administration
·         IO access can be used to obtain blood samples for analysis
·         Use manual pressure or an infusion pump to administer viscous drugs or rapid fluid boluses
·         Follow each medication with a saline flush

Peripheral IVs
·         Placement may be difficult in a critically ill child
·         Give the drug by bolus injection
·         Give the drug during chest compressions
·         Follow drug with 5ml flush of NS


Endotracheal Drug Administration
·         Lipid-soluble drugs, such as lidocaine, epinephrine, atropine, and naloxone (mnemonic “LEAN”)
·         Effects may not be uniform with tracheal as compared with intravenous administration
·         Expert consensus recommends doubling or tripling the dose of lidocaine, atropine or naloxone
·         Epinephrine 0.1 mg/kg or 0.1 mL/kg of 1:1000 concentration is recommended

ET tube Medication Administration
·         Dilute the dose in 2 to 5 mL saline
·         Remove ambu bag from ET tube
·         Inject it into the ET tube
·         Replace ambu bag on ET tube
·         Administer 2 to 3 breaths with the ambu bag

Central IV Drug Delivery
                    Peak drug concentrations are higher and drug circulation times shorter
                    Central line placement can interrupt CPR.
                    A central line extending into the superior vena cava can be used to monitor ScvO2 and estimate CPP during CPR, both of which are predictive of ROSC

Drug Therapy
·         Epinephrine 0.01mg/kg (0.1ml/kg of a 1:10,100 solution) IV or IO
·         Amiodarone 5mg/kg rapid IV/IO
·         Lidocaine 1mg/kg rapid IV/IO bolus
·         Magnesium 25-50mg/kg IV/IO
·         Sodium Bicarbonate 1mEq/kg IV/IO

Wednesday, January 25, 2012

Pediatric Pulseless Ventricular Tachycardia (VT) and Ventricular Fibrillation (VF)


Esophageal Detector Device (EDD)
·         May be considered in children weighing ≥ 20 kg with a perfusing rhythm
·         Insufficient data to recommend for or against its use in children during cardiac arrest


When to Verify Endotracheal Tube Placement
·         Verify proper tube placement immediately after intubation
·         After securing the endotracheal tube
·         During transport
·         Each time the patient is moved (eg, from stretcher to bed)

DOPE Mnemonic
·         If an intubated patient’s condition deteriorates
·         Displacement of the tube
·         Obstruction of the tube
·         Pneumothorax
·         Equipment failure

Exhaled or End-Tidal CO2 Monitoring
·         Recommended as confirmation of tracheal tube position
·         Confirms tube position in the airway but does not rule out right main stem bronchus intubation
·         During cardiac arrest the absence of CO2 may reflect very low pulmonary blood
·         Persistently low PETCO2 values (<10 mm Hg) during CPR in intubated patients suggest that ROSC is unlikely
·         If PETCO2 is <10 mm Hg, it is reasonable to consider trying to improve CPR quality by optimizing chest compression parameters

Note:  Although a PETCO2 value of <10 mm Hg in intubated patients indicates that cardiac output is inadequate to achieve ROSC, a specific target PETCO2 value that optimizes the chance of ROSC has not been established. Monitoring PETCO2 trends during CPR has the potential to guide individual optimization of compression depth and rate and to detect fatigue in the provider performing compressions


End-tidal CO2 Detector may be Altered by the Following:
·         Detector is contaminated with gastric contents or acidic
·         An intravenous (IV) bolus of epinephrine may transiently reduce pulmonary blood flow and exhaled CO2 below the limits of detection
·         Severe airway obstruction and pulmonary edema may impair CO2
·         Large glottic air leak may reduce exhaled tidal volume