PALS Megacode: Unstable Pediatric Bradycardia Part 5

12:05 AM. You are in route to the emergency room with a 12 month old girl with suspected metoprolol overdose. CPR was initiated at the scene and during initial transport. You have given her two fluid boluses and one dose of epinephrine IV. Transcutaneous pacing was initiated in route and is producing a strong brachial pulse. The patient’s skin color is improving and you are now able to obtain a BP and a pulse oximetry reading. She remains unresponsive. Pupils are dilated and nonreactive. Her respirations remain agonal in nature and she continues to require positive pressure ventilations. Her vital signs are BP 66/38. Heart rate 100 (paced). Her skin color has improved as well as her capillary refill.

Complete heart block with external pacing and 100% capture

20.   The patients BP is 66/38.   According to the AHA guidelines, is the systolic pressure above or below normal limits for this 12 month old infant?

a.  The blood pressure is within normal limits

b.  The blood pressure is below normal limits.

21.  When responding to a pediatric cardiac arrest, health care providers are reminded to always look for reversible causes, the Hs and Ts.   Name the Hs and Ts.

22.  When placing pacing electrodes on a pediatric patient, what are some precautions that the rescuer must be aware of?

23.  What is the dose range for an Epinephrine infusion on a pediatric patient?

a.  2-10mg/min

b.  2-10mcg/min

c.   2-10 mcg/kg/min

d. 2-10 units/hr

24.   Dopamine infusions may be used for patients with symptomatic bradycardia, particularly if associated with hypotension, in which atropine may be inappropriate or after atropine fails.  What is the correct dosage range of a dopamine infusion on a pediatric patient?

a.  2-20mcg/min

b. > 10mcg/kg/min

c. 2-20mcg/kg/min

d. 2-10 mg/kg/min

25.  What medications may be indicated for a pediatric patient with a beta-blocker overdose?

a.  Vasopressin

b.  Glucagon

c.  Milrinone

d.  Sodium bicarbonate infusions

Answers

20. b. The blood pressure is below normal limits.

Age                        Minimum SBP (mm Hg)

< 1 month                           <60

1 month- 12months              <70

> 1years                              <70 + (2 x age in yrs)

>10 years                             <90

21.

Hypoxia

Hypothermia

Hyper/hypokalemia

Hypoglycemia

Tablets/toxins

Tension pneumothorax

Tamponade, cardiac

Thrombosis, pulmonary

22. 

Avoids pacemakers

Insure the skin is dry

Avoid medication patches

Avoid letting patches touch

23. b. 2-10mcg/min

24. c. 2-20mcg/kg/min

25. b. Glucagon.
*AHA also recommends:

● High-dose epinephrine infusion may be effective (Class IIb, LOE C).
● Consider glucagon (Class IIb, LOE C).397,400,402,403 In adolescents infuse 5 to 10 mg of glucagon over several minutes followed by an IV infusion of 1 to 5 mg/hour.
● Consider an infusion of glucose and insulin (Class IIb, LOE C)

● There are insufficient data to make a recommendation for or against using calcium (Class IIb, LOE C).

● Calcium may be considered if glucagon and catecholamines are ineffective (Class IIb, LOE C).

*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.