pediatric advanced life support
TRANSCRIPT
ReanimaReanimaReanimaReanimaçççção cardiopulmonar na crianão cardiopulmonar na crianão cardiopulmonar na crianão cardiopulmonar na crianççççaaaa
Antonio SoutoAntonio SoutoAntonio SoutoAntonio [email protected]@[email protected]@bol.com.br
MMMMéééédico coordenadordico coordenadordico coordenadordico coordenadorUnidade de Medicina Intensiva PediUnidade de Medicina Intensiva PediUnidade de Medicina Intensiva PediUnidade de Medicina Intensiva PediáááátricatricatricatricaUnidade de Medicina Intensiva Neonatal Unidade de Medicina Intensiva Neonatal Unidade de Medicina Intensiva Neonatal Unidade de Medicina Intensiva Neonatal
Hospital Padre AlbinoHospital Padre AlbinoHospital Padre AlbinoHospital Padre Albino
Professor de Pediatria nProfessor de Pediatria nProfessor de Pediatria nProfessor de Pediatria níííível II vel II vel II vel II Faculdades Integradas Padre AlbinoFaculdades Integradas Padre AlbinoFaculdades Integradas Padre AlbinoFaculdades Integradas Padre Albino
Catanduva / SPCatanduva / SPCatanduva / SPCatanduva / SP
Paediatric basic and advanced life supportInternational Liaison Committee on ResuscitationResuscitation (2005) 67, 271—291
The ILCOR Paediatric Task Force
Reviewed 45 topics related to paediatric resuscitation.
Causas
� Hipoxemia� Choque� Acidose metabólica/respiratória
Pediatric Advanced Life SupportSimone Rugolotto, MD
Nanjing, China, March 2006
Healthcare professionals may alsocheck for a pulse but should proceedwith CPR if they cannot feel a pulse within 10 s or are uncertain if a pulse
is present
Resuscitation (2005) 67, 271—291
Pediatric Advanced Life SupportSimone Rugolotto, MD
Nanjing, China, March 2006
Pediatric Advanced Life SupportSimone Rugolotto, MD
Nanjing, China, March 2006
Conhecimentos básicos
� Técnica (PALS/CRN)� Unidade (UTIped, UTIneo, PS)
� Fonte de O2
� Aspirador� Material de reanimação� COT, máscaras, ambus
Suporte de vida
� Identificação da PCR� Pedir ajuda� Posicionar o paciente� Desobstruir vias aéreas� Ventilação (ambu)� Massagem cardíaca externa� Acesso venoso� Drogas
Pediatric Advanced Life SupportSimone Rugolotto, MD
Nanjing, China, March 2006
Pediatric Advanced Life SupportSimone Rugolotto, MD
Nanjing, China, March 2006
Posicionamento/Via aérea
� Decúbito dorsal sobre superfície rígida� Cabeça em posição mediana� Leve extensão da cabeça
� Laringe anterior e cefalizada
� Reanimador na cabeceira do paciente
Ventilação
� Definir padrão respiratório (efetivo?)� Definir suporte respiratório� O2 = 100%� Ambu-máscara/COT� Máscara ajustada adequadamente� Ventilação 1 a 1,5 seg (distensão gástrica)� ~ 10 x por minuto� 2:15(30) (Contar em voz alta)
For children requiring airway control orventilation for short periods, bag valve-mask
(BVM) ventilation produces equivalentSurvival rates compared with ventilation with
tracheal intubation.
Resuscitation (2005) 67, 271—291
Until additional evidence is published, we support healthcare providers’ use of
100% oxygen during resuscitation (whenavailable).
Resuscitation (2005) 67, 271—291
Pediatric Advanced Life SupportSimone Rugolotto, MD
Nanjing, China, March 2006
Pediatric Advanced Life SupportSimone Rugolotto, MD
Nanjing, China, March 2006
Pediatric Advanced Life SupportSimone Rugolotto, MD
Nanjing, China, March 2006
Circulação
� Pulsos centrais e frequência cardíaca� Choque ?� Compressão torácica
� Lactentes < 6 meses� Dois dedos� Mãos circundando o tórax� Abaixo da linha intermamilar, linha média sobre o
esterno
The two thumben circling hands chestcompression technique with thoracic squeeze
is the preferred technique for two-rescuerinfant CPR.
The two-finger technique is recommended for one-rescuerinfant CPR to facilitate rapid transition between compression
and ventilation to minimise interruptions in chestcompressions.
Resuscitation (2005) 67, 271—291
Circulação
� Lactentes > 6 meses a 8 anos� Região hipotenar da mão� 2 dedos acima do ap.xifóide, linha média sobre o
esterno
� Comprimir o tórax de 2 a 4 cm� ~ 120 x por minuto� 2:15(30)
Both the one- and two-hand techniques for chestcompressions in children are acceptable provided that
rescuers compress over the lower part of the sternum to a depth of approximately one-third the anterior-posterior
diameter of the chest.
To simplify education, rescuers can be taught the sametechnique (i.e. two hand) for adult and child compressions.
Resuscitation (2005) 67, 271—291
Circulação
� Crianças > 8 anos� Técnica de adultos� 2 mãos� 2 dedos acima do ap.xifóide, linha média sobre o
esterno
� Comprimir o tórax de 3 a 5 cm� ~ 120 x por minuto� 2:15 (30)
Evidence was presented that the ratioshould be higher than 5:1, but the optimal
ratio was not identified
The scientific evidence was sparse, and it was difficult to arrive atconsensus
Compression—ventilation ratio greater than 15:2 came frommathematical models.
Benefit of simplifying training for lay rescuers•single ratio for infants, children, and adults•increase the number of bystanders who will learn, remember, andperform CPR.
Resuscitation (2005) 67, 271—291
For healthcare providers performing two-rescuer CPR, a compression—ventilation
ratio of 15:2 is recommended.
When an advanced airway is established(e.g. a tracheal tube, Combitube, or
laryngealmask airway (LMA)), ventilationsare given without interrupting chest
compressions.
Resuscitation (2005) 67, 271—291
The ILCOR Paediatric Task Force
Emphasis on the quality of CPR is increased:
‘‘Push hard, push fast, minimise interruptions; allow full chest recoil, and don’t
hyperventilate’’.
Acesso venoso
� Técnica� Via venosa periférica
� Bolus de SF 0,9% 5 ml
� Via venosa central� Intra-óssea ( = EV)� Flebotomia (cirurgião)� Via COT
Acesso venoso ?
� Cânula orotraqueal
� Atropina
� Naloxone
� Epinefrina
� L idocaína
Pediatric Advanced Life SupportSimone Rugolotto, MD
Nanjing, China, March 2006
Epinefrina
� Único com eficácia clínica comprovada� Catecolamina endógena
� Alfa = vasoconstrição� Beta = inotropismo +
� Pressão de perfusão
Children in cardiac arrest should begiven 10 mcg/kg of adrenaline as the
first and subsequent intravascular doses.
Routine use of high-dose (100 mcg/kg) intravascular adrenaline is notrecommended and may be harmful, particularly in asphyxia. High-doseadrenaline may be considered in exceptional circumstances (e.g. -blocker overdose).
Resuscitation (2005) 67, 271—291
Pediatric Advanced Life SupportSimone Rugolotto, MD
Nanjing, China, March 2006
VF may be the cause of cardiac arrest in up to 7% to 15% of infants and children.
The treatment of choice for paediatric VF/pulseless VT is promptdefibrillation, although the optimum dose is unknown.
For manual defibrillation, we recommend an initialdose of 2 J /kg
If this dose does not terminate VF, subsequent doses should be 4 J /kg
Resuscitation (2005) 67, 271—291
Pediatric Advanced Life SupportSimone Rugolotto, MD
Nanjing, China, March 2006
Pediatric Advanced Life SupportSimone Rugolotto, MD
Nanjing, China, March 2006
A sobrevida após (PCR) pré-hospitalar é, em média, de aproximadamente 3 a 17% na maioria
dos estudos, e os sobreviventes, freqüentemente, ficam portadores de seqüelas neurológicas graves
Arq Bras Cardiolvolume 70, (nº 5), 1998
One of the most difficult challenges in CPR is to decide the point at which further resuscitative
efforts are futile.
Unfortunately, there are no simple guidelines
Certain characteristics suggest that resuscitation should be continued (e.g. ice water drowning, witnessed VF arrest), and others suggest that furtherresuscitative efforts will be futile (e.g. most cardiac arrests associated withblunt trauma or septic shock)
Resuscitation (2005) 67, 271—291
Should consider whether to discontinue resuscitativeefforts after 15—20 min of CPR
Relevant considerations include the cause of the arrest, preexisting conditions, whether the arrest was witnessed, duration of untreated cardiac arrest (noflow), effectiveness and duration of CPR (low flow), prompt availability ofextracorporeal life support for a reversible disease process, and associatedspecial circumstances (e.g. icy water drowning, toxic drug exposure).
Resuscitation (2005) 67, 271—291
Postresuscitation care
•potential benefits of induced hypothermia on brainpreservation
•preventing or aggressively treating hyperthermia
•glucose control
•vasoactive drugs in supporting haemodynamic function
Resuscitation (2005) 67, 271—291
Postresuscitation care
Hyperventilation after cardiac arrest may be harmful andshould be avoided
The target of postresuscitation ventilation is
normocapnoea
Resuscitation (2005) 67, 271—291
Postresuscitation care
Induction of hypothermia (32 ◦C—34 ◦C) for 12—24 h should be considered in children who remain comatoseafter resuscitation from cardiac arrest
Should prevent hyperthermia and treat it aggressively in infants and children
resuscitated from cardiac arrest
Resuscitation (2005) 67, 271—291
Pediatric Advanced Life SupportSimone Rugolotto, MD
Nanjing, China, March 2006
Postresuscitation care
The combined effects of hypoglycaemia andhypoxia/ischaemia on the immature brain (neonatal animals) appears more deleterious than the effect of eitherinsult alone
Four retrospective studies of human neonatal asphyxia show an association between
hypoglycaemia and subsequent brain injury
Resuscitation (2005) 67, 271—291
Postresuscitation care
Should check glucose concentration duringcardiac arrest and monitor it closely
afterward with the goal of maintainingnormoglycaemia
Glucose-containing fluids are not indicated during CPR unless hypoglycaemia is present
Resuscitation (2005) 67, 271—291