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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

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

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. ·     

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

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

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

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 me

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 ·          D isplacement of the tube ·           O bstruction of the tube ·          P neumothorax ·           E quipment failure Exhaled or End-Tidal CO 2 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 CO 2 may reflect very low pulmonary blood ·          Persis