pediatric advanced life support

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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