Pediatric PEA Part 3

Pediatric PEA

Secondary Survey

·         Intubate

·         Oxygenate

·         IV access

·         Treat reversible causes

Note: Once the patient is intubated, continue CPR with asynchronous ventilations and chest compressions.

Formula for Estimating Endotracheal tube size: 

Uncuffed ET tube:  mm ID = (age in years/4) + 4

Cuffed ET tube:  mm ID = (age in years/4) + 3.5

Confirm ET tube placement

n  Direct cord visualization

n  End-tidal CO2 monitor

n  Purple- problem

n  Yellow- yes

n  Tan- think about it

n  Bilateral breath sounds

n  CXR

n  Continuous waveform capnography

Note:  Continuous quantitative waveform capnography is now recommended for intubated patients throughout the periarrest period as a means of both confirming and monitoring correct placement of an endotracheal tube. 

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

Verification of 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