Dept of Anaesthesia,Govt TDMC,Alleppy. Date:14-10-2014

PEDIATRIC CPCR

NEONATAL CPCR

CPCR IN SPECIAL CONDITIONS Presenter : Dr Sunil Mokashi Senior Resident,

Anaesth Dept Govt TDMCH, Alappuzha.688005 Moderater : Dr Santhosh S.

New born -------------- <4 wks

Infant -------------------- 4 wks-1 year

Child ---------------------- 1 yr -14 yrs

Adult -------------------- >14 year

INTRODUCTION

*Pediatric cardiopulmonary arrest differ from adult cardiac arrest i. e,

1.Adults’ cardiac arrest d/t CAD with severe ischemia and precip-n of malignant arrhythmia, where as children relatively have normal coronary arteries and primary cardiac arrhythmias are uncommon.

2.Initial respiratory compromise/arrest f/b secondary cardiac arrest is common in pediatric age groups.

3. Adults usually display ventricular arrhythmias, w/a children more likely to have bradyarrhythmias that degenerate into asystole.

4.Autonomic nervous system has predominant parasympathetic vagal tone at birth gradually shifts to sympathetic tone in older children.

5.Frank starlings mechanism is less effective in new born, so cardiac output greatly depends on Heart Rate in neonates and children.

Mechanisms of cardiac arrest in pediatric age group. .

1. Respiratory failure[ asphyxial arrest]Asphyxia begins with variable period of systemic hypoxemia

Hypercapnea & Acidosis

Bradycardia and Hypotension

Cardiac arrest2.Another mechanism - Ventricular Fibrilation

/pulseless VT in 5 % 15% of pediatric group. Incidence of both VF and pulseless VT increases with age.

3.Genetic abnormalities in cardiac myocites -> abnormality in ionic flow - >

-> sudden cardiac arrest.

BLS considerations BLS defn- Basic life support is the level of medical

care which is used for the life threatening illnesses or injuries until they can be given full medical care @ hospital.

BLS provided by emergency medical technicians,paramedics, laypersons in prehospital setting can b provided without medical equipment

AHA considers CAB[ circulation, airway, breathing], during BLS.

WHO CAN GIVE BLS ?

Any body from the public or the people in the vicinity of child who has undergone arrest, can start BLS -CPR..! including us.

PALS defn: Refers to the assessment and support of pulmonary and circulatory and cerebral function in the period before an arrest, during and aft an arrest.

Consistant with Chain of Survival ,PALS should focus on prevention of causes of cardiac/ respiratory arrest( sids ,injury,chocking) and early detection and rapid Rx of cardiopulmonary compromise and arrest in critically ill or injured child.

Continuation of BLSCirculation by cardiac

massage/compressionAirway by guedel’s..Breathing by advanced methods….ET

tube,LMA,combitube,tracheostomyDefibrillation manuallyDrugsDd---…search for reversible cause

PALS takes place- organised healthcare environment, multiple trained cpcr providers, ie , critical care physicians/ respiratory therapists/ pediatricians/ anesthetists/critical care nurses.

PALS

Survival rates from pediatric resuscitation[ in hospital cardiac arrest [ infants and children]

1985 - 9%

2000 - 17%

2006 - 27%

2010 - 34% 70% survival rates- in Rapid and effective bystander

CPR, with ROSC & neurologically intact survival in children [ out of hosp cardiac/resp arrest]

Bystander CPR- 20 to 30 % survival in VF [out of hosp arrest]

contd. . . .

Type of cardiac arrest % of survival [in hosp arrests]

1. VF/ Pulseless VT - 34% (survival to discharge)

2. Pulseless E A - 38% , , 3. Asystole - 24% , , 4. Infants and children with pulse but poor perfusion & bradycardia who required - 64 % cpr.

Source-pediatric data National Registry of Cardiopulmonary Resuscitation

[NRCPR-2008]

Pediatric BLS

ABC or BAC ?

The 2010 AHA guidelines recommend CAB sequence, ie.

Chest compressions Airway

Breathing / Ventilation

During cardiac arrest a high quality CPR particularly essential to generate,

blood flow to vital organs and ROSC.

Infant BLS guidelines apply- to infants less than 1 yr of age.

Child BLS guidelines- children from 1yr to puberty.

Adult BLS guidelines -At puberty and beyond.

Asphyxial cardiac arrest is more comon than VF cardiac arrest in

infants and children , so ventilations are extremly important in pediatric

resuscitation.

BLS Sequence for Lay Rescuers

1. Assess the need for CPR.

>Lay rescuer should assume that CARDIAC ARREST is present

if the victim is UNRESPONSIVE.

2. Check for response.

> Gently tap the victim and ask loudly “ Are you okay ?”

>Look for any injuries and if child needs medical assistance.

>If child is responsive and breathing- leave child and activate

Emergency Response System.

> If child unresponsive - shout for help. Contd….

3. Check for Breathing>If breathing regular and victim does not need CPR No evidence of trauma

Turn child into recovery position( maintain patent airway and decrease risk of aspiration)

> If child is unresponsive, not breathing/ Gasping

Start CPCR

4. Start chest compressions - Push fast - 100 chest compressions

per minPush hard- push atleat 1/3 rd AP diameter of chest contd…..

Depth of chest compression-

infant- 1 .1/2 inchs or 4cm

children- 2 inches/ 5cm

Things to be kept in mind while giving CHEST COMPRESSION

> Allow complete chest recoil after each compression to allow the

heart to refill with the blood.

> Minimise interuruptions of chest compression .

> Avoid excessive ventilation.

5. Open airway and give ventilations :

> A compression to ventilation ratio of 30: 2 recommended.

> Open airway by Head tilt - Chin lift maneuver for both

injured and non injured pt’s.

> In infants Mouth to Mouth and Mouth to Nose technique for giving

breaths

> If difficult in making effective seal, use,

1. Mouth to mouth techn- pinch nose.

2.Mouth to nose technique – close mouth

Coardinate chest compressions and breathing:-

After 2 effective breaths

30 compressions immediately

Continue the cycles for 2 min /5cycles before leaving the victim to activate

Emergency Response System to obtain AED.

Rescuer should return to victim as soon as possible use either AEDor start CPR

Continue the cycles of 30 chest compressions to 2 ventilations until ERS

arrives.

Fig: Pediatric Chain of Survival showing , 1.early CPR, 2 early EMS actvn,

3. AED cardioversion 4 . Tranport for early PALS,

5. PALS 6. additional links- definitiv care and rehabilitation of child.

BLS sequence for Health Care providers

BLS health care providers work in team Unlike layperson guidelines, Chest compressions and securing airway

for rescue breathing happen simulteneously. Health care providers should focus mostly on cause of arrest in child

and act accordingly.

Ex: If health care providers witness, a arrest or sudden collapse in an

adolescent or a child( child identtified tto b at risk of arrhytthmia or in

athletic event), the HCP may assume that victtim has suffered a sudden VF,-cardiac arrest. As soon as rescuer verifiesthe child is unresponsive

& not breathing(even gasping) ,then he should phone ERS get AED,

begin CPR and use AED…

BLS STEPS1.Asssess the Need for CPR:

Unresponsive ,nonbreathing, gasping individual, send some

one to activate Emergency Response System

2. Check pulse :

10 seconds only to check pulse

brachial - infant , carottid or femoral -> child

Absent pulse/ difficulty in feeling pulse -> begin chest compressions

BLS STEPS3. Inadequate Breathing with pulse.

Pulse ≥ 60 but no adequate breathing

rescue breaths 12 to 30 breaths per min till spontaneous breathing

resumes

Reassess pulse every 2 min (assess in < 10 seconds)

Bradycardia with poor Perfusion:

pulse <60 pm & signs of poor perfusion + despite support with

oxygenattion and ventilations

begin chest compressions

Because infants and children largely depend on heart rate .

Profound bradycardia (< 60 witth signs of poor perfusion )is indication for

chest compressions and CPCR

Chest Compressions.

Child unresponsive / not breathing / no pulse

Start Chest compressions.Types: 1. Two finger chest compression for infants

2. Two thumb encircling hand technique- Recommended when CPR provided by 2 rescuers

The ‘2 thumb encircling hands technique ‘ preferred over Two finger technique- because former produces ,Higher coronaryartery perfusion pressure and adequate depth of chest compression.

Two finger technique of chest compression

Two thumb encircling hands technique of chest compression ( two rescuers)

# 30 compressions (15 compressions if two rescuers)

# Open airway with head tilt and chin lift and give 2 breaths

# use head tilt ,chin lift maneure if jaw thirst is not opening airway

Coordinate chest compressions:Lone rescuer- 30:2 and 2 rescuers - 15 : 2.

100 compresssions per min

8 to 10 breaths per min and abreath every 6 to 8 seconds

Ventilations:

Defibrillation:

Shockable rhythms- VT and Pulseless VT

AEDs are equipped with attenuation of energy delivered ,that is required in chil

Dose of first shock - 2J/kg Dose of 2nd shock- 4J/kg

AED wil prompt rescuer to re analyse the rhythm every 2 min

Shock delivery should occur as soon as possible after chest compression

BAG and MASK Ventilation

Prefered – EC clamp technique of bag – mask ventilation

Self inflating bag with 450- 500 ml volume can b used.

To deliver high O2 concentration(60% to 95%) attach oxygen reservoir to

self inflating bag Maintain O2 flow rate of 10 to 15 L/min into reservoir

attached to pediatric bag

Avoid excessive ventilation

Pt with airway obstruction or poor lung compliance require high

inspiratory pressure.

Two person Bag Mask Ventilation

>helpful when significant airway obstruction, poor lung compliance ordifficulty in creating tight seal b/n mask and face.

> one person holds mask and create tight seal, other gives bag compressions

EC clamp technique of holding bag and mask for ventilation

Thumb and indexfinger on either side of mask to make ‘c’ and holding mask againt pt mouth,f/b using other 3 fingers to lift the angle of jaw fingers forming ‘ E’

Airway adjuncts

Oropharyngeal airways

Nasopharyngeal airways

Cuffed oropharyngeal airways

ENDOTRACHEAL TUBE PLACEMENT ET intubation - indicated at several points

during neonatal resuscitation:

1. Tracheal suctioning for meconium

2. Bag-mask ventilation is ineffective / prolonged

3.When chest compressions are performed

4.When ET administration of medications is required

5.Congenital diaphragmatic hernia or extremely low birth weight (<1000 g)

Place a pillow under the head and neck but NOT under the shoulders

This allows a straight line of vision from

the mouth to the vocal cords The laryngoscope is introduced into the

right hand side of the mouth (it is held by the left hand

The tongue is swept to the left and the tip of the blade is advanced until a fold of skin / cartilage is visualised at twelve o’ clock

This is the epiglottis, and this sits over the glottis (the opening of the larynx) during swallowing

The tip of the blade is advanced to the base of the epiglottis, known as the vallecula, and the entire laryngoscope is lifted upwards and outwards

This flips the epiglottis upwards and exposes the glottis below

An opening is seen with two white vocal cords forming a triangle on each side

The tip of the ET tube is advanced through the vocal cords and once the cuff has passed through, one stops advancing The tube is secured at this level and the cuff inflated

PEDIATRIC CPCRAmerican Heart Association

guidelines [2010 ] for PALS[Pediatric Advanced Life Support]

Pulseless cardiac arrest:

When child is unresponsive with no breathing , get an AED/manual defib

-rillator High quality CPCR should be given

throughout rescuscitation. Determine cardiac rhythm by ECG. And

decide shockable or non shockable like Asystole or pulseless cardiac arrest.

Non Shockable rhythm : Asystole /PEA

PEA defn- It is organised electrical activity most commonly slow and wide QRS complexes without palpable pulse

Another entity- EMD( Electro Mechanical Dissociation) -> there is

sudden impairment of Cardiac output with an initially normal rhythm

EMD is more reversible than Asystole

FOR Asystole and PEA

> Continue CPCR with less interruptions to chest compressions

Another rescuer gives Epinephrine aft IV/IO access @0.01mg/kg(0.1 ml/kg of 1: 10 000 solution) & Dose repeated every 3 to 5min

With advanced airway in place one should give chest compressions100/min without pause for ventilation.

second rescuer delivers 1 breath every 6 to 8 sec(8 to 10 breaths per min)

Check rhythm every 2min,if rhythm nonshockable continue CPCR& Epinephrine admn. Till there is evidence of ROSC

If rhythm becomes shockable deliver shock. Search for and treatreversible causes.

PEA

Asystole

Shockable Rhythm. (VF/pulseless VT).

Defibrillation is definitive treatment of choice for VF with overall survival of 17% to 20%

AED or manual defibrillators can b used for delivering shocks

Paddle size of defibrillator wil b Adult size (8 to 10 cm ) for children >

10kg(Aproximatly 1 yr)Infant size for infants<10 kg

Paddle position : For AED or moniters /defibrillator pads

follow package directions

For manual pads place one pad over rt side of upper chestand another at the apex of the heart (to the left of the nipple over left lower ribs)

VF and pulseless VT)

Energy Dose.

For VF – dose of 2 to 4 j/kg.

In refractory cases- 4J/kg and susequent doses should b atleast 4J/kg

Higher energy levels must be considerd but not to exceed 10J/kg

Pediatric Bradycardia-

> Emegency Rx of bradycardia indicated when it results into hemodynamic

changes.

> Support airway breathing and circulation, of pulses perfusion and respirations are adequate no emergency Rx required.

> If bradycardia is <60bpm with poor perfusion continue to support airway ,ventilation, oxygenations and chest compressions.

if bradycardia persists /transiently responding, give Epinephrine IV/IO

0.01mg/kg bw(0.1 ml/kg of 1:10000 solution)

> If bradycardia is due to increased Vagal Tone or primary AV conduction

block – iv/io atropine 0.02 mg/kg or ET dose of 0.04 to 0.06mg/kg can b given

Pediatric Tachy cardia

Signs of poor perfusion and nonpalpable pulse-> proceed to pulseless arrest algorithm.

+ve pulse with poor perfusion> assess and support BAC> provide O2>Attach monitor/defibrillator>obtain vascular access>Evaluate 12 lead ECG and assess QRS duration

Narrow complex (< 0.09 second) Tachycardia: > 12 Lead ECG pts clinical presentation and

history wil help to differentiate sinus tachycardia from SVT

Supraventricular Tachycardia

> Monitor rhythm and degree of hemodynamic instability

> Attempt vagal stimulation – apply ice to face in infnts and young children without occluding airway.

> In older children carotid sinus massage or valsalva maneurs are safe.

> Pharmacological cardioversion - Adenosine DOC.

adenosine 0.1 mg/kg IV/IO should be given rapidly and flushed with > /= 5ml normal saline.

> Verapamil 0.1 – 0.3 mg/kg IV/IO effective in terminating SVT, should not be used in infants since can cause potential myocardial depression, hypotension and cardiac arrest

SVT contd…

> If Pt is hemodynamically unstable- sync cardioversion

start with 0.5 to 1 J /kg then increase the dose i to 2J/kg durind 2nd shock.

> If 2nd shock unsuccessful – consider Amiodarone-5mg/kg IO/IV or

procainamide 15 mg/kg IV/IO.

> Both amiadarone and procainamide should be given with slow infusion at the rate of over 20 to 30 min (amiadarone) and 30 to 60 min( procainamide)under expert consultation.

> Should moniter ECG and BP during infusion. If no effect or no signs of toxicity give additional doses

Wide Complex ( > 0.09 second) Tachycardia

# Originate in ventricle (ventricular tachycardia) but may be Supraventricular in origin.

# Adenosine may be helpful in differentiating SVT from VT and converting

wide complex tachycardia of supraventricular origin .

# Adenosine should be considered – if rhythm is regular and QRS complex is monomorphic.

# Do not use adenosine in patients with Wolf – Parkinson White Syndrome

Contd. .

# Consider electric cardioversion after sedation using energy dose of

0.5 to 1 J /kg If that fails increase the dose to 2J/kg

# Consider pharmacologic conversion with IV amiadarone(5mg/kg over 20 to 60 min) or procainamide ( 15mg/kg given over 30 to 60 min) with ECG and BP monitoring

Stop and slow the infusion if there is decline in BP/QRS widens

# In hemodynamically unstable pts - Electric Cardiversion .

0.5 J/kg in 1st shock then increase to 2J/kg susequently.

Torsades Pointes- Type of polymorphic VT associated with long QT interval

may be congenital or due to toxicity with type 1A antiarrhythmics

( procainamide, quinidine,and disopyramide) ,type III (sotolol,amiadarone) TCA’s digitalis ‘drug interactions.

Rx:- #This rapidly converts to VF or Pulseless VT.

#Initiate CPCR proceed to defibrillation when pulseless arrest develops.

#treat Torsades pointes with rapid infusion of MgSo4 @ dose of

25- 50mg/kg; max single dose-2gm)

In different situations# Septic shock-

> crystalloid is prefered initial fluid of choice than colloid.

> Monitoring central venous O2 saturation(ScvO2) useful to titrate the therapy in infants and children with septic shock. Target therapy of

ScvO2 >/= 70% improve pt survival in severe sepsis.

> Early assisted ventilation may b considered as part of protocol driven strategy in septic shock.

> Etomidate known to facilitate ET Intubation in infants and young children

Caution: Etomidate should not be used routinely in pediatric patients

Adrenal supression is seen aft use of Etomidate in children

and adults.

Hypovolemic shock Use of crystalloids RL or NS as initial fluid is

recommended No role of adding colloid in early phase of resuscitation Rx signs of shock with bolus of 20 ml/kg crystalloid even if

BP normal.

Crystalloids have survival benefit over colloids for children with

general trauma ,traumatic brain injury, and burns. Additional boluses (20ml/kg) of crystalloids is given if

systemic perfusion

fails to improve.

NEONATAL RESUSCITATION

ANTICIPATION/ RISK FACTORSMaternal• Prolonged rupture of membranes (greater than 18 hours) • Bleeding in second or third trimester • Pregnancy induced hypertension • Chronic hypertension • Substance abuse • Drug therapy (e.g. lithium, magnesium, adrenergic blocking agents, narcotics) • Diabetes mellitus • Chronic illness (e.g. anaemia, cyanotic congenital heart disease) • Maternal pyrexia • Maternal infection • Chorioamnionitis • Heavy sedation • Previous fetal or neonatal death • No prenatal care

Fetal-

Multiple gestation (e.g. twins, triplets) Preterm gestation (especially less than 35 weeks) Post term gestation (greater than 41 weeks) Large for dates Fetal growth restriction Alloimmune haemolytic disease (e.g. anti-D, anti-Kell, especially if fetal anaemia or hydrops fetalis present) Polyhydramnios and oligohydramnios Reduced fetal movement before onset of labour Congenital abnormalities which may effect breathing, cardiovascular function or other aspects of perinatal transition Intrauterine infection Hydrops fetalis

Intrapartum Non reassuring fetal heart rate patterns on cardiotocograph (CTG) Abnormal presentation Prolapsed cord Prolonged labour (or prolonged second stage of labour) Precipitate labour Antepartum haemorrhage (e.g. abruption, placenta praevia, vasa praevia) Meconium in the amniotic fluid Narcotic administration to mother within 4 hours of birth Forceps birth Vacuum-assisted (ventouse) birth Maternal general anaesthesia

2010 American Heart Association Guidelines for CardiopulmonaryResuscitation and Emergency Cardiovascular Apply primarily to newly born infants undergoing transition from intrauterine to extrauterine lifeAlso applicable to neonates during the first few weeks to months following birth.

Approximately 10% of newborns require some assistance to begin breathing at birth.

Less than 1% require extensive resuscitative measures.

INITIAL ASSESMENT

• Term gestation• Crying or breathing• Good muscle tone

If ‘YES’; no resuscitationBaby

DriedCovered with dry linenPlaced close to the

motherMonitor

breathing,activity and colour

If ‘NO’- ResuscitationA. Initial steps B. VentilationC. Chest compressionsD. Medications or volume

expansionE. Post resuscitation care

Initial steps

Provide warmthSniffing positionDry the babyStimulate breathingClear airway( if needed)

Initial steps(temperature control)Important for very LBW(<1500g) preterm babies

Radiant heatExothermic mattressCovering with heat resistant plasticPre warming delivery room to 26 degrees temp monitored closely

Initial steps(clearing the airway)

•Immediate suctioning following birth

Obvious obstruction to spont breathing

Require PPV•No routine nasopharyngeal or

oropharyngeal suctioning•Nasopharyngeal suctioning can create bradycardiaEndotracheal suction of nonvigorous babies with MSAF(meconium stained\ amniotic fluid )

Initial steps(stimulate breathing)

•Rub the baby’s abdomen or back up and down

•Flick the underside of the baby’s foot with your fingers.

Suctioning the airway Mouth 1st then nose Gentle and intermittent Bulb syringe , de Lee suction 2 to 3 sec Depth of suction about 3

inches/7cm No aggressive suction Electrical suction : negative

pressure < 100mm Hg Aggressive throat suction can cause

mucosal trauma and stimulation of posterior pharynx leading to vagal stimulation, bradycardia and laryngospasm

Healthy, vigorous crying babies do not need any suctioning

Golden minuteApproximately 60 sec for initial steps, re-evaluation and beginning B

After initial steps

Assess simultaneously

1. Heart rate - > or < 100 beats/min

2. Respiration – apnea, gasping, labored or unlabored breathing

Heart Rate

Primary vital sign to judge need and efficacy of resuscitation

Auscultate precordium(better and most accurate)

Palpation of the umblical pulse

Positive pressure ventilation

Ind: if infant after initial stepsApneic gaspingH.R < 100/minProvided by Bag mask ventilationMonitor SpO2

Ventilation

For term babies- ie > or = 37 wksinitiate resuscitation with room air(21%)Step up- based on H.R; if H.R < 60 after 30s of ventilationsupplementary oxygen- by blending oxygen and airGradual step up to 100%Guided by pulse oximetry

For preterm babies- ie < 32 weeksinitiate resuscitation with blended oxygen and airO2 conc between 30-90%Guided by pulse oximetryTitrate O2 conc accordingly

Ventilation

Rate – 40 to 60 breaths/minInitial inflation pressure- 20 to 25 cm of H2O for preterm and 30 to 40 cm of H2O for termTarget- H.R 100/minPEEP likely to be beneficial in pretermMonitor with CO2 detectors to identify airway obstruction

Assisted ventilation

Evaluation after 30 seconds of ventilationHeart rateState of oxygenationRespirationIncrease in HR most sensitive indicator of resuscitation efficacy

Assessment once PPV started

If H.R < 100 & > 60

Take ventilation corrective steps

Assess chest wall movement

HR<60Start chest compressionsCo-ordinate with PPVConsider Intubation

Targeted SpO2 After Birth1 minute 60 to 65%2 minutes 65 to 70%3 minutes 70 to 75%4 minutes 75 to 80%5 minutes 80 to 85%10 minutes 85 to 95%same for both term and preterm

Chest compressions

Ind: H.R < 60/min after vent with supplementary O2 for 30sSite- lower 3rd of sternumDepth- one third of AP diameter of chest

Chest compressions

Ratio- 3:1Rate- 90 compressions and 30 vent.s/min

Compressions and ventilations coordinatedAvoid simultaneous deliveryChest allowed to reexpand fully during relaxationThumbs should not leave the chestAvoid frequent interruptions

Method-

With 2 thumbs- fingers encircling the chest and supporting the backWith 2 fingers- 2nd hand supporting the back2 thumb-encircling hands tech generate higher peak systolic and coronary perfusion pressureRecommended in newly borns

Techniques

Medications and volume expansion

Ind- H.R < 60/min despite adequate ventilation with 100% O2 and chest compressionsRarely indicated

Epinephrine

Dose- 0.01 to 0.03 mg/kg/doseConc- 1: 10000 Intravenous0.05 to 0.1 mg/kg through ET tube

Volume expansionInd:Blood lossSuspected blood loss- pale skin,poor perfusion,weak pulseInadequate H.R response to resuscitation

Volume expansion

Isotonic crystalloid solution or bloodDose: 10 ml/kgRate:Intraventricular hemorrhage- rapid infusions esp in premature infants

Assisted-Ventilation Devices

1. A flow inflating or self inflating bag

2. T- piece3. LMA4. ET tube

For newborns >2000g or delivered > or = 34 wks gestationIf face mask ventilation unsuccessful and tracheal intubation unsuccessful or not feasibleNot in MSAF, during CPR and for drug administration

LMA

ET intubationIndications:•Initial endotracheal suctioning of nonvigorous meconium stained newborns•If bag-mask vent ineffective or prolonged•During chest compressions•Special resuscitation- Cong diaphragmatic hernia or extremely LBW

Confirmation of ET tube placement- by exhaled CO2 detectionET suctioning is recommended in nonvigorous babies with MSAFIf intubation attempt prolonged or severe bradycardia ,consider bag-mask vent/PPV

The Endotracheal tube sizeThe Endotracheal tube size usually is 3.5 for term baby and 2.5 for a preterm baby. A malleable but rigid stylet may be introduced into the Endotracheal tube for ease of intubation, But be careful not to cause trauma. The tip of the stylet should not extend beyond the Endotracheal tube

ET Tube size

Weight in grams

Gestational age (Weeks)

2.5 <1000 283 1000-2000 28-343.5 2000-3000 34-384 >3000 >38

Nasal prongs

Nasal prongs are an alternative way of giving PPV

CPAPMay be administered to preterm infants who breath spontaneously but with difficultyAdvantage- reduce intubation,surfactant use and durn of ventilationDisadv- Pneumothorax

Post resuscitation careRisk for deteriorationClose monitoring and anticipatory careAvoid hypoglycemia; Glucose infusion- for newborns with low blood glucoseNaloxone not routinely recommended even if mother has opioid exposureInduced therapeutic hypothermia-

Induced Therapeutic Hypothermia

Induced therapeutic hypothermia- whole body or selective head coolingOffered to infants born at >/= 36 wks with evolving moderate to severe hypoxic-ischemic encephalopathyStart within 6 hrs following birth,continue for 72 hrs and slow rewarming over 4 hrs

Withholding ResuscitationExtreme prematurity(gest age < 23 wks or birth wt < 400g)AnencephalyMajor chromosomal anomalies( trisomy 13)

Discontinuation of resuscitation

H.R undetectable for 10 min

In situations of prolonged bradycardia with

heart rate < 60 /min for > 10-15 min, there is

insufficient evidence to make recommendation

regarding continuation or discontinuation of

resuscitation

Resuscitation step

2005 2010

Assessment for resuscitation need

4 questions 3

Airway Clear airway Assure open airwayNo routine suctioning

Assessment after initial steps

H.RColorRespiration

H.RResp

Checking H.R By palpating umblical cordpulsations

Auscultating precordium

Major changes in AHA guidelines

Ind.s for PPV H.R,apnea/gasping and central cyanosis

Cyanosis out

Assessment once PPV started

H.RColorrespiration

H.RPulse oximetryRespiration

Assessment of oxygenation

Based on colorPulse oximetry for only< 32weeks withneed for PPV

Based on pulse oximetryfor both term and preterm

Target saturation Not defined defined

Initial O2 conc for PPV

Term-Start with 100% O2 during PPV< 32wks-start with O2 conc between 21 and 100

Term-Start with room air (21%)<32 wks-O2 conc between 30 and 90%

Initial breath strategy for PPV

No specific PIPrecommendation

PIP- for initial breaths 20-25 cm H2O for preterm and30-40 cm H2O for someterm babies

No specificrecommendation for PEEP

PEEP likely to be beneficialfor initial stabilization ofpreterm infants

Guiding of PPV looking atchest rise and improvementin heart rate

Guide the PPV looking atheart rate and oxygenationespecially in preterm, chestrise less reliable

Use of LMA For near term and term infants >2500g may be used

LMA may be used for infants>2000g and ≥ 34 weeks

Upper airway interface

PPV by nasal prongssuperior to facial masks forproviding

Chest compression cardiac arrest is dueto a clear cardiac etiologywhere ratio of 15:2 may beconsidered

Naloxone considered Not recommended

TherapeuticHypothermia

Not routinely recommended

Recommended for ≥ 36 wks with moderate tosevere hypoxic ischemicencephalopathy

Apgar Score

Described first by an anaesthetist Virginia Apgar in 1952,it still holds good for assessing the baby’s condition and for prognostication of the neurological status

•It is simple •reproducible •universally accepted •popular score •It is a simple useful guide to neonatal well-being and resuscitation

•Apgar Score

The first apgar score is assigned at 1 minute only and hence the decision to start resuscitation cannot be based on that. however, the apgar score at 5 minutes is important to assess the effectiveness of resuscitation.If the score is 6 or less, then the baby should be assessed again at 10, 15 and 20 minutes (Extended Apgar score).A low Apgar score at 10 minutes or later is associated with a poor prognosis.If the score is 3 or less at 15 minutes, the chance for brain damage and cerebral palsy is >57%Apgar scoring should continue every 5 min. until the scoring is >7

Acronym observation 0 1 2A Appearance (Color) Blue or pale Periphery blue Pink

P Pulse (Heart) rate Nil Less than 100 100 or more

G Grimace (reflex with catheter in nostril)

No Response Grimace Cry or sneeze

A Activity (muscle tone) Flaccid Some flexion of limbs

Semi-flexed: active

R Respiration Nil Slow, irregular Crying

Heart rateNormal:120-160 beats/minutesMax: 220 beats/minutes< 100 beats means low cardiac output and poor tissue perfusion

CauseUsually asphyxiated neonates Other causes CHD ,Congenital Heart block, and congestive heart failure

DiagnosisPrenatal ECG and echo cardiogram

Respiratory EffortsThe respiratory rate is not considered

only the quality of respiratory effortBreathing usually begins by 30 sec. of

extra uterine life and sustained by 90 sec of Age

Normal : 30-60 breaths /min◦ There is no pause between inspiration and

expiration ◦ It helps to develop and maintain a normal

FRC

Apnoea and BradypnoeaAcidosisAsphyxiaMeternal drugsInfections

MeningitisPneumoniaSepticemia

TachypnoeaHypoxiaMetabolic and respiratory acidosisCNS hemorrhageHyaline membrane disease Pulmonary edemaAspirationMaternal drugs: alcohol ,Mg, Narcotics, barbiturates

Muscle Tone AsphyxiaMaternal drugsCNS damage Myasthenia Gravis

Reflex IrritabilityHypoxiaAcidosisMaternal drugsCNS InjuryCongenital muscle disease

ColorBlue tinged at birth60 sec. :pink90 sec. : if central cyanosis

AsphyxiaLow cardiac outputPulmonary edemaMethemoglobinemiaPulmonary disorders

Lung HypoplasiaDiapharagamatic herniaAirway obstructionRespiratory distress

If pale Asphyxia Hypovolemia AcidoticCongenital heart disease

If rubrousPolycythemia

If pinkIntoxicated with

AlcoholMgAlkalotic pH>7.5

•Peripheral cyanosis (acro- cyanosis) is a normal phenomenon in a newborn, but is given a score of one only. Totally pale (asphyxia pallida) and centrally blue (Asphyxia livida) babies are given identical scores, even though, the former is more grave.•Muscle tone and reflex response are dependent on the gestational age of the baby. Low birth weight preterm babies have feeble tone and reflex and hence will have a low score•The decision to start resuscitation is not based on Apgar score and in fact , started earlier as soon as the baby is not breathing•There is poor correlation between Apgar score and future neuro- developmental outcome. However, if the Apgar score continues to be low at 10 and 15 minutes after birth, the chances of cerebral palsy is as high as 60%

Fallacies of Apgar Score

CPCR IN SPECIAL SITUATIONS

Cardiac Arrest AssociatedWith Asthma

BLS unchanged.Ventilation strategy - low respiratory rate and tidal volume – to dilute the effects of auto PEEP

adverse effect of auto-PEEP on coronary perfusionpressure and capacity for successful defibrillation has beendescribed in patients in cardiac arrest without asthma.51,52 Moreover,the adverse effect of auto-PEEP on hemodynamics inasthmatic patients who are not in cardiac arrest has also beenwell-described. since the effects of auto-PEEP in an asthmatic patient with cardiac arrest are likely quite severe, a ventilation strategy of low respiratory rate and tidal volume is reasonable

During arrest a brief disconnection from the bag mask or ventilator and compression of the chest wall to relieve air-trapping can be effectiveTension pneumothorax should be considered and treated

For all asthmatic patients with cardiac arrest, and especially for patients in whom ventilation is difficult, the possible diagnosis of a tension pneumothorax should be considered and treated

Cardiac Arrest AssociatedWith AnaphylaxisEarly and rapid advanced airway management is critical and should not be unnecessarily delayed. Intramuscular epinephrine Recommended dose is 0.2 to 0.5 mg (1:1000) IM to be repeated every 5 to 15 minutes in the absence of clinical improvement

DrowningMost detrimental consequence - hypoxia; therefore, oxygenation, ventilation, and perfusion should be restored as rapidly as possibleCPR for drowning victims should use the traditional A-B-C approach in view of the hypoxic nature of the arrest

Open the airway, Check for breathing, and If there is no breathing, give 2 rescue breaths . Begin chest compressions and provide cycles of compressions and ventilations according to the BLS guidelines. Attach an AED and attempt defibrillation if a shockable rhythm is identifiedIf hypothermia – treat accordingly

Cardiac Arrest Associated WithElectric Shock and Lightning StrikesBe sure of ones own safetyInitiate standard BLS resuscitation careMaintain spinal stabilization if there is a likelihood of head or neck traumaStandard ACLS CAREEarly intubation for patients with extensive burns

The primary cause of death in victims of lightning strike iscardiac arrest, which may be associated with primary VF orasystole. Lightning acts as an instantaneous, massivedirect-current shock, simultaneously depolarizing the entiremyocardium. In many cases intrinsic cardiac automaticitymay spontaneously restore organized cardiac activity and aperfusing rhythm. However, concomitant respiratory arrest dueto thoracic muscle spasm and suppression of the respiratorycenter may continue after ROSC. Unless ventilation is supported,

Cardiac Arrest AssociatedWith TraumaLook for and correct reversible causes of cardiac arresthypoxia hypovolemiadiminished cardiac output secondary to pneumothorax or pericardial tamponadehypothermia

BLS Modifications

Provide standard CPR and defibrillationIn multisystem trauma or head and neck traumaStabilize cervical spine Airway by jaw thrustAvoid head tilt– chin lift If breathing is inadequate and the patient’s face is bloody, ventilation should be provided with a barrier device, a pocket mask, or a bag-mask device while maintaining cervical spine stabilization.Stop any visible hemorrhage using direct compression and appropriate dressings.

ACLS Modifications trauma ptsIf bag-mask ventilation is inadequate, an advanced airway should be inserted while maintaining cervical spine stabilization.Consider a cricothyrotomy.

Cardiac Arrest inAccidental HypothermiaIf pt is in pre arrestprevent further loss of heat and rewarm the victim immediately.Removing wet garments and insulate from further environmental exposurestransport to a center where aggressive rewarming is possible

mild hypothermia- passive rewarmingModerate hypothermia- external warming techniquesa. forced airb. Surface warming devices.severe hypothermia- core rewarming c. Warmed IV or intraosseous (IO)

fluids and d. Warm humidified oxygen.

If pt is in cardiac arrestbegin CPR without delayremove wet garments and protect the victim from additional environmental exposure.Rewarming attempted when feasible

ACLS Modifications - hypothermiaAggressive active core rewarming techniques as the primary therapeutic modality.1. CPB2. Warm water lavage of thoracic

cavity3. Extracorporeal blood warming

with partial bypass administration of a vasopressor during cardiac arrest according to the standard ACLS algorithmAfter ROSC, patients should continue to be warmed to a goal temperature of approximately 32° to 34°C

Cardiac Arrest Caused byCardiac Tamponade

Emergency pericardiocentesisThoracotomy

Cardiac Arrest Associated WithPulmonary EmbolismOften presents as pulseless electric activityIn patients with cardiac arrest due to presumed or known PE, it is reasonable to administer fibrinolytics

Commotio Cordis

VF triggered by a blow to the anterior chest during a cardiac repolarizationCommonly seen in young persons who are engaged in sportsPrompt recognition that a precordial blow may cause VF is critical.Rapid defibrillation is often life-saving

Cardiac Arrest Associated WithLife-Threatening Electrolyte Disturbances

Current BLS and ACLS should be used to manage cardiac arrest associated with all electrolyte disturbances.

ACLS Modifications in Management of SevereCardiotoxicity or Cardiac Arrest Due to Hyperkalemia Administer adjuvant IV therapy in addition

to standard ACLSStabilize myocardial cell membrane:

Calcium chloride (10%): 5 to 10 mL (500 to 1000 mg) IV over 2 to 5 minutes or calcium gluconate (10%): 15 to 30 mL IV over 2 to 5 minutes

Shift potassium into cells: Sodium bicarbonate: 50 mEq IV over 5 minutes

ACLS Modifications in Management of Cardiac Arrestand Severe Cardiotoxicity Due to Hypermagnesemia

Administration of calcium (calcium chloride [10%] 5 to 10 mL or calcium gluconate [10%] 15 to 30 mL IV over 2 to 5 minutes) may be considered

ACLS Modifications in Management of Cardiac Arrestand Severe Cardiotoxicity Due to Hypomagnesemia

For cardiotoxicity and cardiac arrest, IV magnesium 1 to 2 g of MgSO4 bolus IV push

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