Pediatric Resuscitation
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Since the 1980s, significant advancements have been made in pediatric resuscitation training in the United States. In 1988, the American Heart Association (AHA) offered the first course in Pediatric Advanced Life Support (PALS). This course was designed for pediatric healthcare providers at all levels and taught basic approaches to pediatric cardiopulmonary arrest with a heavy emphasis on algorithms. In 1984, the American Academy of Pediatrics (AAP) and the American College of Emergency Physicians (ACEP) offered the first course in Advanced Pediatric Life Support (APLS). This course was designed to be more comprehensive and covered a spectrum of pediatric emergencies in addition to basic resuscitation. Over the last 20 years, these two programs have become the predominant courses required by hospitals across the United States for pediatric healthcare providers.
Overall survival to discharge in pediatric patients with an out-of-hospital cardiac arrest has remained low and relatively unchanged at 6%. These poor outcomes may be attributable in part to the fact that only one third to one half of these patients receives bystander cardiopulmonary resuscitation (CPR). Of those that survive out-of-hospital arrest, many suffer permanent brain injury. This is in contrast to the overall survival in pediatric patients with in-hospital cardiac arrests which has increased from 9% to 27%. This is believed to be attributable to earlier recognition and management of critical conditions, earlier CPR, and the implementation of medical emergency teams with specialists trained in the acute resuscitation of pediatric patients using the PALS and APLS algorisms.
In a pediatric resuscitation, understanding the anatomical differences from adults is paramount. They are most pronounced in children younger than 8 years.
The tongue is larger relative to the mouth and has a greater tendency to collapse and obstruct the airway. Tonsils are larger and may bleed with trauma. This makes blind nasotracheal intubation much more difficult in children. The epiglottis is larger, floppier, and more acutely angled, making it more likely to obstruct the view of the vocal cords during intubation. Because of this, a straight blade may be required. The larynx is higher, relative to adults. It is at C1 in infants, C3 in toddlers, and C6 in adults. It is also more anterior and more likely to collapse on inspiration. Avoid hyperextension of the neck and use a straight blade to help visualize the anatomy. The narrowest point of the airway in a child younger than 8 years is the cricoid cartilage, not the subglottic area. This makes correct tube size more important, especially if using an uncuffed tube. An infant’s occiput is larger than an adult. For children younger than 2 years, a roll under the shoulders helps properly position theairway.For children older than 2 years, place a roll under the head to improve the view.
Pulses in an infant younger than 1 year should be palpated at the brachial artery on the medial aspect of the upper arm. For children older than 1 year, the neck should be long enough that the most accessible central artery will be the carotid. Infants have a lower functional residual capacity and higher oxygen consumption per minute giving them a greater tendency to become hypoxic.
In cases of airway edema, noxious stimuli may precipitate a respiratory arrest in a tenuous child. Keeping the child calm is extremely important in this situation. Because of their higher vagal tone, children are more prone to bradycardia with airway manipulation. Atropine may help blunt this effect (see Medications).
Normal vital signs vary by age. Basic guidelines are below: [1]
See the list below:
Neonate: 80-180 beats per minute (BPM)
1 week to 1 month: 80-160 BPM
3 month to 2 years: 80-150 BPM
2-10 years: 75-110 BPM
10 years to adult: 50-100 BPM
See the list below:
Term infant: 30-50 BPM
1 -6 months: 20-40 BPM
6 months to 2 years: 20-30 BPM
2-12 years: 16-24 BPM
Adolescents: 12-20 BPM
In children that require resuscitation, blood pressure may be normal. If the child appears ill, fluids and medications should not be delayed because the blood pressure remains normal. Hypotension in a child is often a sign of decompensated shock and reason for swift intervention. For the 2010 PALS guidelines, hypotension is defined as a systolic blood pressure:
< 60 mm Hg in term neonates (0-28 d)
< 70 mm Hg in infants (1-12 mo)
< 70 mm Hg + (2 × age in years) in children 1-10 years
< 90 mm Hg in children ≥10 years
Pediatric resuscitation is a broad topic. This article discusses basic principles in the recognition and management of pediatric cardiopulmonary arrest and its causes. For more information, see the following related topics:
Considerations in Pediatric Trauma
Respiratory failure and shock are the most common causes of cardiopulmonary arrest in the pediatric population. These tend to be progressive conditions in which a period of time is observed between the onset of illness and the clinical deterioration into full cardiopulmonary arrest. Consequently, the timely recognition and management of respiratory failure and shock are essential goals of pediatric resuscitation.
This is an important distinction from cardiopulmonary arrest in adults which is typically caused by cardiac dysrhythmias. Only 5-15% of pediatric in-hospital or out-of-hospital arrests are found to have ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT) as the initial rhythm. That being said, pulseless VT and VF have also been shown to occur as frequently as 27% at some point during in-hospital resuscitations. Their management, along with the management of other cardiac dysrhythmias, pulseless electrical activity (PEA), and asystole are essential goals of pediatric resuscitation.
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Marc Auerbach, MD, MSCI Associate Professor of Pediatrics, Associate Professor of Emergency Medicine, Yale University School of Medicine; Associate Trauma Medical Director, Associate Director of Pediatric Simulation, Yale New Haven Children’s Hospital; Director of Pediatric Simulation, Yale Center for Medical Simulation
Marc Auerbach, MD, MSCI is a member of the following medical societies: American Academy of Pediatrics, International Network for Simulation-based Pediatric Innovation, Research, and Education, International Pediatric Simulation Society, Pediatric Academic Societies, Pediatric Trauma Society
Disclosure: Nothing to disclose.
Disclosure: Nothing to disclose.
Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference
Disclosure: Nothing to disclose.
Dharmendra J Nimavat, MD, FAAP Associate Professor of Clinical Pediatrics, Department of Pediatrics, Division of Neonatology, Southern Illinois University School of Medicine; Staff Neonatologist, Clinical Director, NICU Regional Perinatal Center, HSHS St John’s Children’s Hospital
Dharmendra J Nimavat, MD, FAAP is a member of the following medical societies: American Academy of Pediatrics, American Association of Physicians of Indian Origin
Disclosure: Nothing to disclose.
Ted Rosenkrantz, MD Professor, Departments of Pediatrics and Obstetrics/Gynecology, Division of Neonatal-Perinatal Medicine, University of Connecticut School of Medicine
Ted Rosenkrantz, MD is a member of the following medical societies: American Academy of Pediatrics, American Pediatric Society, Eastern Society for Pediatric Research, American Medical Association, Connecticut State Medical Society, Society for Pediatric Research
Disclosure: Nothing to disclose.
Andrew R Edwards, MD, FACEP Associate Professor of Emergency Medicine, Vice-Chair for Education and Residency Program Director, Department of Emergency Medicine, University of Alabama at Birmingham School of Medicine; Medical Director, Jefferson County SWAT Team, Jefferson County Sheriff’s Department
Andrew R Edwards, MD, FACEP is a member of the following medical societies: American College of Physicians, Society for Academic Emergency Medicine, Wilderness Medical Society
Disclosure: Nothing to disclose.
James Stuart Booth, MD Emergency Physician, Assistant Professor, Assistant Medical Director, Department of Emergency Medicine, University of Alabama at Birmingham School of Medicine
James Stuart Booth, MD is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.
Arianna Shirk, MD Fellow in Pediatric Emergency Medicine, University of Alabama at Birmingham School of Medicine
Disclosure: Nothing to disclose.
Pediatric Resuscitation
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