kuliah pals-fkik untan.ppt
TRANSCRIPT
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Emergency in Pediatrics
FKIK UNTAN
Oct 7th, 2011
Dr. Rini Andriani, Sp A
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RAPID CARDIOPULMONARY
ASSESSMENT (9) Sensorium Skin Color
Respiratory Rate / Effort Skin Temperature Cardiac Rate and Rhythm Quality of Pulses
Capillary Refill Time Blood Pressure Urine Output
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RAPID CARDIOPULMONARY ASSESSMENTCLASSIFICATION OF PHYSIOLOGIC STATUS
Stable
Respiratory Failure
Potential airway and breathing problems
Probable fails to improve or deterioratesdespite therapy
Shock Compensated
Decompensated hypotension
Cardiopulmonary Failure
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Many Etiologies
Respiratory Failure Shock
Cardiopulmonary Failure
Cardiopulmonary Arrest
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PRIMARY ABNORMALITIES IN
RESPIRATORY FA ILURE
Airway
&Breathing
Circulation
Ventilation
Oxygenation
Perfusion
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PRIMARY ABNORMALITIES INSHOCK
Airway
&Breathing
Circulation
Ventilation
Oxygenation
Perfusion
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Recognition of Potential
Respiratory Failure Airway patency (upper versus lower airway
obstruction)
Air entry: Chest rise, breath sounds, stridor,wheezing
Respiratory Rate: too fast or too slow
Respiratory Effort: Accessory muscles,retractions, grunting, head bobbing, nasal flaring
Heart rate, pulses, skin perfusion
Level of consciousness
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Approach to Patient withPotential Respiratory Failure
Open airway and assist ventilation as
neededAdminister oxygen
Monitor heart rate, respirations, pulse
oximetry Obtain arterial blood for gas analysis and
electrolytes, and perform chest x-ray
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Case Scenario - BreathingProvide Oxygen
Awake Nonrebreathing
mask
Altered mental status
or breathing difficulty Bag-valve mask Unresponsive or Endotracheal
respiratory failure intubation
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RAPID CARDIOPULMONARY ASSESSMENTPRIORITIES OF INITIAL MANAGEMENT
POTENTIALRESPIRATORY FAILURE
PROBABLERESPIRATORY FAILURE
Keep with caregiver Separate from caregiver
Position of comfort Control airway
Oxygen as tolerated100% FiO2
Assist ventilation
Nothing by mouth Nothing by mouth
Monitor pulse oximetry Monitor pulse oximetry
Consider cardiac monitorCardiac monitor
Establish vascular access
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BASIC RELATIONSHIPS OF
CARDIOVASCULAR PARAMETERS
BloodPressure
CardiacOutput
SystemicVascularResistance
StrokeVolume
HeartRate
Preload
MyocardialContractility
Afterload
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HEMODYNAMIC RESPONSE TO
HEMORRHAGE
Vascular
resistance
Bloodpressure
Cardiac
output
Compensated
shock
Decompensated
shock
140
100
60
20Percentofco
ntrol
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CARDIAC OUTPUT
= heart rate X stroke vo lume
Compensation
heart rate systemic vascular
resistance
possible strokevolume
Inadequate
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DEVELOPMENT OF SHOCK FROMPULSE RATE DISTURBANCES
PULSE
RATE
CO = HR X SV
Fast = X
Slow = X N Absent 0 = 0 X 0
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REVIEW OF THE
PHYSICAL FINDING IN SHOCK
Early signs (Compensated)
heart rate poor systemic perfusion
Late signs (Decompensated)
weak central pulses
Altered mental status
urine output hypotension
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DEFINITION OF
CARDIOPULMONARY FAILURE
Deficits in
Ventilation
Oxygenation
Perfusion
Resulting in
Agonal respiration
Bradycardia
Cardiopulmonary Arrest
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Many Etiologies
Respiratory Failure Shock
Cardiopulmonary Failure
Cardiopulmonary Arrest
Death Cardiopulmonary Recovery
ImpairedNeurologic
Recovery
UnimpairedNeurologic
Recovery
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Secondary Brain InjuryTrauma
Shock Hypoxia
Hypotension IntracranialPressure
Decreased
Cerebral Perfusion
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Pediatric Trauma
Isolated Head Multiple(CNS) injury Trauma
Airway compromise
Respiratory failure
Shock
Cardiopulmonary Arrest(final common pathway)
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Age Minimum systolic bloodpressure (5th percentile)
0 to 1 month 60 mm Hg
>1 month to 1 year 70 mm Hg
1 to 10 years of age 70 mm Hg + (2 age in years)
>10 years of age 90 mm Hg
Lower Limits of Normal Systolic
Blood Pressure by Age
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RAPID CARDIOPULMONARY ASSESSMENTPRIORITIES OF INITIAL MANAGEMENT
SHOCK
Administer oxygen (FiO2 = 1.00) andensure adequate airway and ventilation
Establish vascular access
Provide volume expansion
Monitor oxygenation, heart rate, andurine output
Consider vasoactive infusions
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RAPID CARDIOPULMONARY ASSESSMENTPRIORITIES OF INITIAL MANAGEMENT
CARDIOPULMONARY FAILURE
Oxygenate, ventilate, monitor Reassess for :
respiratory failure
shock
Obtain vascular access
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Treatment of Shock
Initial rapid fluid administration of
20 mL/kg of
Crystalliod
Colloid Blood
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Resuscitation of Hemorrhagic Shock
Estimated blood volume = 80 mL/kg
(EBV) of a child 25% of EBV = 20 mL/kg
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Algorithm for Fluid Resuscitation inShock
20 mL/kg crystalloid
REASSESS
20 mL/kg crystalloidREASSESS
20 mL/kg crystalloid or 10 mL/kg colloid
REASSESS
20 mL/kg crystalloid or consider 10 to 20 mL/kg colloid or
packed red blood cells
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Hazard of Glucose-ContainingInfusions
5% dextrose contains
5 g/100 mL
1 g/20 mL
20 mL/kg = 1 g glucose/kg
Avoid use of glucose-containing solutionsto replace volume
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Treatment of Acute Metabolic AcidosisCaused by Dehydration
Restore circulating blood volume
Maximize respiratory compensation
Treat underlying cause
The use of bicarbonate is controversial
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Advantages of Intubation in Shock
Facilitates delivery of maximal FiO2 Decreases work of breathing Enables controlled hyperventilation
Ensures control of airway
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INTRAOSSEOUS NEEDLE PLACEMENT
1-2 cm distal and medial to
tibial tubercle
Perpendicular to flat
surface of bone
Secure purchase,
aspirates, easy flow
Marrow space
noncollapsible veins for
easy absorption to circulation
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INTRAOSSEOUS NEEDLE IN PLACE
Over 6 years: distal tibia Under 6 years:proximal tibia
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DRUGS THAT CAN BE GIVENENDOTRACHEALLY
Lidocaine
EpinephrineAtropine
Naloxone
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ENDOTRACHEAL DRUG DELIVERY
Epinephrine dose is 10 x IVdose:
0.1 mg/kg (use 1:1000)
Other drug doses are increased2x to 3x IV dose
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INOTROPES IN POSTARREST SHOCK
Postarrest shock
Fluid Bolus
Reassess
Hypotensive Normotensive
Epinephrine or
Dopamine Infusion
Dobutamine,Epinephrine or
Dopamine
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TREATMENT OF SEPTIC SHOCK
the initial priority is fluidresuscitation
use inotropes to treat myocardialdepression
use vasopressors to correcthypotension
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COMPARISON OF INOTROPIC DRUGS
DRUG USES
Epinephrine
Symptomatic bradycardiaShock (including anaphylactic)
Hypotension
Cardiopulmonary Arrest
Dobutamine Normotensive cardiogenic shock
Dopamine
Low Improve renal, splanchnic blood flow
High Hypotension
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PREPARATION OF DRUG INFUSIONS :The Rule of 6
DRUG CALCULATION RULE
Epinephrine 0.6 x body wt (kg) = # mg toadd to diluent to make 100 mlvolume
1 ml / hr del ivers 0.1 ug/kg/min
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The Rule of 6
DRUG CALCULATION RULE
Dopamine
Dobutamine
6 x body wt (kg) = # mg toadd to diluent to make 100 ml
volume
1 ml / hr del ivers 1.0 ug/kg/min
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REVIEW OF INOTROPE USE
DRUG DOSAGE REMARKS
Epinephrineinfusion
Begin at 0.1ug/kg/minHigher dose used during
CPR
Titrate todesired effect
Dobutamine 2 20 ug/kg/min Titrate todesired effect
DopamineHCl
2 20 ug/kg/minAdrenergic
actiondominates at 15 20 ug/kg/min
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Airway: Stabilize and maintainBreathing : Maintain adequate ventilation
and oxygenation
Circulation : Maintain adequate organperfusion
Disability : Assess the central nervoussystem
Evaluate : Evaluate other systems and theetiology of arrest
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STABILIZATION -AIRWAY
Frequently assess airway clinically
Consider endotracheal intubation
Tape the tube securely NGT
CXR
Sedation ?
Muscle relaxants ?
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STABILIZATIONAIRWAYSEDATIVES / MUSCLE RELAXANTS
FORVENTILATED PATIENTS
Commonly used sedatives
Diazapam 0.1 to 0.2 mg/kg/ IV Morphine 0.1 to 0.3 mg/kg/ IV
Commonly used postintubation muscle relaxant Pancuronium 0.1 mg/kg/ IV
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STABILIZTION - BREATHING
Establish ventilator parameters
Assess adequacy of breathing with Physical examination
Oxygen saturation monitor
End-tidal CO2 ABG
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STABILIZATION - CIRCULATION
Establish two vascular lines Provide maintenance fluids :
D5 0.25% NS infusion
WEIGHT INFUSION RATE< 10 kg 4 ml/kg /hr
10 to 20 kg40 ml/h + 2ml/kg/hr for
each kg > 10 kg
> 20 kg60 ml/h + 1ml/kg/hr for
each kg > 20kg
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STABILIZATION - CIRCULATION
Fluid boluses / vasopressors
Evaluate
heart rate monitor
End-organ perfusion
Urine Output Heart size on Chest x-ray
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STABILIZATION - DISABILITY
Perform brief neurologicexamination with assessment
of vital signs
hyperventilate if increased
intracranial pressure issuspected
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STABILIZATIONEVALUATION OF OTHER SYSTEMS
control patients temperature
measure blood glucose andcorrect hypoglycemia
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STABILIZATION EVALUATIONLABORATORY / RADIOGRAPHY
Chest Xray
ABG
Serum electrolytes
Glucose
BUN / creatinine
CBC
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Thank You
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CASE SENARIO
A 2-year old boy, approximately 12 kg, hasbeen resuscitated after a submersion injury. Herequired CPR, intubation, & pharmacologic andfluid resuscitation. His cervical spine is
immobilized; he is responsive only to painfulstimuli.
Vital Signs HR : 110 bpm RR : 10 breath per min
BP : 90/55 mmHg Temp : 36.2 C
What would you do first?
How should the patient be stabilized?
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CASE - STABILIZATION
AIRWAY
Assess / listen
Tape Endotracheal
Tube
Nasogastric Tube
CXR
Sedation asNeeded
BREATHING
listen / watch
ABG
Monitor : HR,
O2 saturation,end tidal CO2
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CASE - STABILIZATION
Circulation two vascular lines maintenance fluids
blood samples for laboratory analysisDisability Assessment
brief examination of the centralnervous system
CASE VENTILATORY
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CASEVENTILATORY
PARAMETERS
What are the patients initial
ventilator settings? FiO2
Ventilation rate?
Tidal Volume? PEEP?
Inspiratory time?
GUIDELINES FOR VENTILATORY
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GUIDELINES FOR VENTILATORY
SETTINGS
FiO2 : 1.00 (100%)
Rate : 16 to 20 per min
Tidal Volume : 10-15 ml/kg
Inspiratory time : 0.051.0 sec
Peak inspiratory Pressure : 2030 cmH2O
PEEP : 24 cm H2O
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CASE - PROGRESSION
After adequate sedation, the patient isrelaxed and is mechanically ventilated.
What would be his maintenance and
bolus fluids.
Bolus Composition ?
Amount ?
Maintenance Composition ?
Infusion rate ?
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REVIEW OF FLUIDS
Maintenance
D5 0.25% normal saline
Rate : 40 ml/hr + (2 kg x 2 ml/hr)
= 44 ml/hr
Boluses: 20 ml/kg = 240 mlnormal saline or LRS
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CASE
PROGRESSIONThe patients glucose is 20
mg/dl by bedside analysis
What fluid would you give now?
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CASEPROGRESSION
The patient now has two IV lines inplace, is on a mechanical ventilator,and is sedated.
How can each of the following beclinically assessed?
Respiratory Status
Cardiovascular Status
Neurologic Status
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ONGOING ASSESSMENT
Respiratory Cardiovascular Neurologic
Chest rise Heart rate/RhythmLevel of
Consciousness
Breath Sounds Pulse Quality Pupillary Response
Cyanosis Capillary Refill
AgitationLevel of
ConsciousnessPulse-oximetry Urine Output
End-tidal CO2 Blood Pressure
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CASE :
LABORATORY & RADIOLOGY
Which blood test are indicated?
Which radiologist studies are
important?
What other test might be considered?
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CLINICAL PARAMETER
What additional clinical
parameters should be evaluated?
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ANSWER
Temperature monitoring and
stabilization. Medications as indicated.
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STABILIZATION/ TRANSPORT
Pediatric Intensive Care Area
Improved survival of critically illchildren
Provide a spectrum of some servicesfor postresuscitation of patients
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TRANSPORT
This patient requires intensive
care. The nearest facility is
100 miles away.
What do you do now?
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TRANSPORT DECISIONS
mode of transport
transport team
transport triage
preparation for transport
communication post-transport follow-up
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CASE PROGRESSION
While awaiting the transport team,the intubated child becomes
cyanotic. He is beginning to moveand seems agitated.
What additional assessment shouldbe done immediately?
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ASSESSMENT OF VENTILATION,
OXYGENATION, AND PERFUSION
heart rate: 170 bpm
pulses weak peripherally
skin cyanotic chest hyperexpanded with decrease breath
sounds on the right side
ABG: pH 7.11 PaCO260, Pa O240
What is your assessment? What is your plan?
ASSESSMENT
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ASSESSMENTPOSSIBLE TENSION PNEUMOTHORAX
PLAN
Check oxygen source
Check ventilator settings
Remove from ventilator; manually ventilate
Confirm endotracheal tube position andpatency
Suction the endotracheal tube Consider needle thoracostomy
Should a chest radiograph be performed to
confirm the diagnosis?
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NEEDLE THORACOSTOMY
A needle is inserted in the secondintercostal space in the
midclavicular line, and a rush of airis noted. The patients color and vitalsigns improve, but he remains
agitated.
What do you consider now?
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CASE PROGRESSION
You contact the tertiary hospital and
inform them of the patients status
What and with whom should you
communicate?
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TRANSPORTCOMMUNICATION
Physician to physicial
nurse to nurse
provide information
brief history
treatment
current clinical status
change in clinical staturs
T A S O T
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TRANSPORTIMMEDIATE PREPARATION
Secure the airway, I Vs, spine, and any
fractures
copy patient charts copy patient radiograph
gather blood products
provide laboratory phone numbers
prepare consent
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ASSESSMENT OF
CARDIOVASCULAR FUNCTION
Assess ventilation, heart rate, end-
organ perfusion, peripheral pulses,
blood pressure Is CPR needed?
Is cardiovascular instability present
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FAST PULSE :
NARROW VENTRICULAR COMPLEX
SUPRAVENTRICULAR TACHYCARDIA (SVT) vs
SINUS TACHYCARDIA (ST) : HISTORY
SINUS TACHYCARDIA SUPRAVENTRICULAR
TACHYCARDIA
fever
pain
volume loss
diarrhea, vomiting, bleeding
irritability, lethargy
poor feeding
tachypnea sweating
pallor
hypothermia
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FAST PULSE :
NARROW VENTRICULAR COMPLEX
SUPRAVENTRICULAR TACHYCARDIA (SVT) vs
SINUS TACHYCARDIA (ST) : HEART RATE
SINUS
TACHYCARDIA
SUPRAVENTRICULAR
TACHYCARDIA
P waves Present & Normal Absent or abnormal
RR / PR
Variable RR w/
constant PR
Abrupt rate change to
or from normal
Infants < 220 bpm > 220 bpm
Children < 180 bpm > 180 bpm
FAST PULSE WIDE COMPLEX VENTRICULAR
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FAST PULSE: WIDE-COMPLEX VENTRICULARvsSUPRAVENTRICULAR TACHYCARDIAWITH ABERRANCY
Wide-complex tachycardia should be considered
ventricular in origin
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SHOCK 2O TO TACHYARRYTHMIA WITH
PULSE : TREATMENT
ETIOLOGY TREATMENT
Narrow QRS
Probable SVT
adenosine (if vascular accessavailable)
synchronized cardioversion
Wide QRS
Probable VT
synchronized cardioversion
lidocaine
bretylium
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DRUG TREATMENT OF SVT
ADENOSINE
0.1 to 0.2 mg/kg
Maximum single dose: 12 mg
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ETIOLOGY OF BRADYCARDIA
hypoxemia
drugs
cardiac disease (rare)
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CASE STUDY: SLOW PULSE
A 3 month old infant presents with
respiratory rate of 10/min central pulse rate of 45 bpm
absent peripheral pulses
mottled skin
capillary refill > 5 seconds
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SLOW PULSE TREATMENT
Epinephrinevs
Atropine
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EPINEPHRINE TREATMENT OFSYMPTOMATIC BRADYCARDIA
IV / IO Dose ET Dose
0.01 mg/kg 0.1 mg/kg
0.1ml/kg of
1:10,000
0.1 ml/kg of
1:1000
ATROPINE TREATMENT OF
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ATROPINE TREATMENT OF
SYMPTOMATIC BRADYCARDIA
IV / IO dose
0.02 mg/kg
Minimum dose
0.1 mg
Maximum single dose (may repeat once)
Child : 0.5 mg
Adolescent : 1 mg
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CASE STUDY: ABSENT PULSE
A 8 y/o submersion victim with
apnea no palpable pulses
What arrhythmias could be present?
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ABSENT PULSE
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ABSENT PULSE :
(COLLAPSE RHYTHMS) ASYSTOLE
TREATMENT
CPR
Secure Airway
Hyperventilate with 100% oxygen
Obtain IV or IO access Epinephrine q 3 5 min
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ABSENT PU SE VENTRICU AR
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ABSENT PULSE: VENTRICULARTACHYCARDIA / FIBRILLATION
CPR
Defibrillate up to 3 times if needed
Epinephrine / Defibrillate
Lidocaine / Defibrillate
Bretylium / Defibrillate
ABSENT PULSE: VENTRICULAR
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ABSENT PULSE: VENTRICULAR
TACHYCARDIA / FIBRILLATION
DRUG DOSAGE REMARKS
Lidocaine Bolus 1 mg/kg
Lidocaine
Infusion
(120 mg lidocaine/100
ml diluent)
20-50 ug/kg/min
(1-2.5 ml/kg/hr)
Bolus of 1 mg/kg
needed if
lidocaine bolus
has not beenadministered in
previous 15 min.
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CASE STUDY : ABSENT PULSE
PULSELESS ELECTRICAL ACTIVITY
ELECTROMECHANICAL DISSOCIATION
A 2 y/o child was struck by an automobile
Respiratory rate = 0 (apnea)
Central pulse = absent
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98/106
ABSENT PULSE : PEA / EMDTREATMENT
CPR (ventilation, oxygenation, chest
compressions)
Epinephrine every 3-5mins
Treat cause
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99/106
ABSENT PULSE : PEA / EMD
Potentially correctable causes
severe hypoxia
hypovolemia tension pneumothorax
cardiac tamponade
severe acidosis
electrolyte disturbances
hypothermia
SUMMARY OF THERAPY BY PULSE
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SUMMARY OFTHERAPY BY PULSERATE IN CHILD WITH SHOCK
PULSE RATE TREATMENT
Fast
Synchronized cardioversion
Adenosine (in SVT if IV access available)
Slow Ventilation, oxygenation, compressions,
epinephrine
Absent
(collapse)
CPR
VF or VT: immediate fibrillation
PEA/EMD : identify and treat cause
Epinephrine
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VENTRICULAR FIBRILLATION
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102/106
VENTRICULAR TACHYCARDIA
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103/106
SINUS TACHYCARDIA
SUPRAVENTRICULAR
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SUPRAVENTRICULAR
TACHYCARDIA
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105/106
ASYSTOLE
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106/106
WARNING
Treat the patient
Not the Rhythm