Pediatric Advance Life Support: Aystole Part 5

Vasoconstrictors

·         Epinephrine 0.01mg/kg (0.1ml/kg of a 1:10,100 solution) IV or IO

·         Epinephrine 0.1mg/kg (0.1ml of a 1:1000 solution) via ET tube

·         May repeat dose every 3-5 minutes

Evaluate Reversible Causes

·         Hypoxia- use DOPE mnemonic

·         Hypovolemia- 20ml/kg fluid bolus

·         Hyper/hypokalemia- correct imbalance

·         Hypothermia- consider rewarming techniques
·         Hypoglycemia- correct low blood sugar

Note:  DOPE mnemonic- D: displacement of tube, 0: obstruction of tracheal tube, P: pneumothorax, E: Equipment failure

Management of PEA is exactly the same as for asystole. Interventions for specific causes of PEA may lead to successful resuscitation. Appropriate measures may include a rapid fluid bolus for potential hypovolemia (20 mL/kg normal saline or lactated Ringer’s administered IV or IO), needle decompression for suspected tension pneumothorax, ventilation and sodium bicarbonate for acidosis, or pericardiocentesis for cardiac tamponade as regional protocols permit.

Evaluate Reversible Causes 

·         Tension pneumothorax- needle decompression

·         Tamponade: pericardiocentesis

·         Tables/toxins: tx based on specific toxin

·         Thromboembolism: rare and difficult to treat
·         Trauma- may be unrecognized by health care provider

Note:  In tension pneumothorax, PEA results when air trapped within 1 side of the chest pushes the mediastinum toward the opposite side. If this shift is extreme, venous blood return to the heart is occluded by kinks in the great vessels above and below the mediastinum. The heart continues to contract, giving rise to normal electrical activity on cardiac monitoring, but no blood is entering the heart, so there is no palpable pulse.

In cardiac tamponade, PEA results when blood or other fluid fills the pericardial sac that surrounds the heart, preventing it from pumping normally and markedly decreasing cardiac output. When the ventricles contract during systole, the pressure between the pericardium and myocardium decreases and additional fluid enters the sac. When the ventricles relax during diastole, pressure from the fluid in the pericardial space prevents them from returning to their normal volume. This presents classically with hypotension, muffled heart sounds, and distended neck veins (Beck’s Triad); the latter two findings may be difficult to discern in infants.

Note:  Management of PEA is exactly the same as for asystole. Interventions for specific causes of PEA may lead to successful resuscitation. Appropriate measures may include a rapid fluid bolus for potential hypovolemia (20 mL/kg normal saline or lactated Ringer’s administered IV or IO), needle decompression for suspected tension pneumothorax, ventilation and sodium bicarbonate for acidosis, or pericardiocentesis for cardiac tamponade as regional protocols permit

Post-resuscitation

·         Maintain normal ventilation

·         Monitor temperature

·         Manage post-ischemic myocardial dysfunction

·         Maintain normal glucose

Consider Termination of Efforts

The final decision to stop can never rest on a single parameter, such as duration of resuscitative efforts. Rather, clinical judgment and respect for human dignity must enter into decision making. In the out-of-hospital setting, cessation of resuscitative efforts in adults should follow system specific criteria under direct medical control.

Family Presence during Resuscitation

·         Designated staff member should be available to support and remain with family during resuscitation

·         Positive psychological effects  for family members  

·         Planning, staff acceptance

·         Be sensitive to family members presence while team members communicate among themselves

Sources

Pediatric Advanced Life Support Provider Manual by Leon, M.D. Chameides, Ricardo A., M.D. Samson, Stephen M., M.D. Schexnayder and Mary Fran, RN Hazinski (Oct 12, 2011)Fink EL, Freid EB, Hickey RW, 

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