pediatric-ALS-AHA-guidelines-circulation_11-2010 - SSM Cardinal ...

More documents

Recommendations

Info

S880 Circulation November 2, 2010the presence of water vapor in the tube, 105 is completelyreliable, use both clinical assessment and confirmatory devicesto verify proper tube placement immediately afterintubation, again after securing the endotracheal tube, duringtransport, and each time the patient is moved (eg, fromgurney to bed) (Class I, LOE B).The following are methods for confirming correct position:● Look for bilateral chest movement and listen for equalbreath sounds over both lung fields, especially over theaxillae.● Listen for gastric insufflation sounds over the stomach.They should not be present if the tube is in the trachea. 104● Check for exhaled CO 2 (see “Exhaled or End-Tidal CO 2Monitoring,” below).● If there is a perfusing rhythm, check oxyhemoglobinsaturation with a pulse oximeter. Remember that followinghyperoxygenation, the oxyhemoglobin saturation detectedby pulse oximetry may not decline for as long as 3 minuteseven without effective ventilation. 106,107● If you are still uncertain, perform direct laryngoscopy andvisualize the endotracheal tube to confirm that it liesbetween the vocal cords.● In hospital settings, perform a chest x-ray to verify that thetube is not in a bronchus and to identify proper position inthe midtrachea.After intubation, secure the tube; there is insufficientevidence to recommend any single method. After securing thetube, maintain the patient’s head in a neutral position; neckflexion may push the tube farther into the airway, andextension may pull the tube out of the airway. 108,109If an intubated patient’s condition deteriorates, consider thefollowing possibilities (mnemonic DOPE):● Displacement of the tube● Obstruction of the tube● Pneumothorax● Equipment failureExhaled or End-Tidal CO 2 MonitoringWhen available, exhaled CO 2 detection (capnography orcolorimetry) is recommended as confirmation of tracheal tubeposition for neonates, infants, and children with a perfusingcardiac rhythm in all settings (eg, prehospital, emergencydepartment [ED], ICU, ward, operating room) (Class I,LOE C) 110–114 and during intrahospital or interhospital transport(Class IIb, LOE C). 115,116 Remember that a color changeor the presence of a capnography waveform confirms tubeposition in the airway but does not rule out right mainstembronchus intubation. During cardiac arrest, if exhaled CO 2 isnot detected, confirm tube position with direct laryngoscopy(Class IIa, LOE C) 110,117–120 because the absence of CO 2 mayreflect very low pulmonary blood flow rather than tubemisplacement.Confirmation of endotracheal tube position by colorimetricend-tidal CO 2 detector may be altered by the following:● If the detector is contaminated with gastric contents oracidic drugs (eg, endotracheally administered epinephrine),a consistent color rather than a breath-to-breath colorchange may be seen.● An intravenous (IV) bolus of epinephrine 121 may transientlyreduce pulmonary blood flow and exhaled CO 2below the limits of detection. 120● Severe airway obstruction (eg, status asthmaticus) andpulmonary edema may impair CO 2 elimination below thelimits of detection. 120,122–124● A large glottic air leak may reduce exhaled tidal volumethrough the tube and dilute CO 2 concentration.Esophageal Detector Device (EDD)If capnography is not available, an esophageal detector device(EDD) may be considered to confirm endotracheal tubeplacement in children weighing 20 kg with a perfusingrhythm (Class IIb, LOE B), 125,126 but the data are insufficientto make a recommendation for or against its use in childrenduring cardiac arrest.Transtracheal Catheter Oxygenationand VentilationTranstracheal catheter oxygenation and ventilation may beconsidered for patients with severe airway obstruction abovethe level of the cricoid cartilage if standard methods tomanage the airway are unsuccessful. Note that transtrachealventilation primarily supports oxygenation as tidal volumesare usually too small to effectively remove carbon dioxide.This technique is intended for temporary use while a moreeffective airway is obtained. Attempt this procedure onlyafter proper training and with appropriate equipment (ClassIIb, LOE C). 127Suction DevicesA properly sized suction device with an adjustable suctionregulator should be available. Do not insert the suctioncatheter beyond the end of the endotracheal tube to avoidinjuring the mucosa. Use a maximum suction force of -80 to-120 mm Hg for suctioning the airway via an endotrachealtube. Higher suction pressures applied through large-borenoncollapsible suction tubing and semirigid pharyngeal tipsare used to suction the mouth and pharynx.CPR Guidelines for Newborns With CardiacArrest of Cardiac OriginRecommendations for infants differ from those for the newlyborn (ie, in the delivery room and during the first hours afterbirth) and newborns (during their initial hospitalization and inthe NICU). The compression-to-ventilation ratio differs(newly born and newborns – 3:1; infant two rescuer - 15:2)and how to provide ventilations in the presence of anadvanced airway differs (newly born and newborns – pauseafter 3 compressions; infants – no pauses for ventilations).This presents a dilemma for healthcare providers who mayalso care for newborns outside the NICU. Because there areno definitive scientific data to help resolve this dilemma, forease of training we recommend that newborns (intubated ornot) who require CPR in the newborn nursery or NICUreceive CPR using the same technique as for the newly bornin the delivery room (ie, 3:1 compression-to-ventilation ratioDownloaded from circ.ahajournals.org by on October 20, 2010
Kleinman et al Part 14: Pediatric Advanced Life Support S881with a pause for ventilation). Newborns who require CPR inother settings (eg, prehospital, ED, pediatric intensive careunit [PICU], etc.), should receive CPR according to infantguidelines: 2 rescuers provide continuous chest compressionswith asynchronous ventilations if an advanced airway is inplace and a 15:2 ventilation-to-compression ratio if no advancedairway is in place (Class IIb, LOE C). It is reasonableto resuscitate newborns with a primary cardiac etiology ofarrest, regardless of location, according to infant guidelines,with emphasis on chest compressions (Class IIa, LOE C). Forfurther information, please refer to Part 13, “Pediatric BasicLife Support,” and Part 15, “Neonatal Resuscitation.”Extracorporeal Life Support (ECLS)Extracorporeal life support (ECLS) is a modified form ofcardiopulmonary bypass used to provide prolonged deliveryof oxygen to tissues. Consider early activation of ECLS for acardiac arrest that occurs in a highly supervised environment,such as an ICU, with the clinical protocols in place and theexpertise and equipment available to initiate it rapidly. ECLSshould be considered only for children in cardiac arrestrefractory to standard resuscitation attempts, with a potentiallyreversible cause of arrest (Class IIa, LOE C). 128–154When ECLS is employed during cardiac arrest, outcome forchildren with underlying cardiac disease is better than theoutcome for children with noncardiac disease. With underlyingcardiac disease, long-term survival when ECLS is initiatedin a critical-care setting has been reported even after 50minutes of standard CPR. 128,129,139,147MonitoringElectrocardiographyMonitor cardiac rhythm as soon as possible so both normaland abnormal cardiac rhythms are identified and followed.Continuous monitoring is helpful in tracking responses totreatment and changes in clinical condition.EchocardiographyThere is insufficient evidence for or against the routine use ofechocardiography in pediatric cardiac arrest. When appropriatelytrained personnel are available, echocardiography maybe considered to identify patients with potentially treatablecauses of the arrest, particularly pericardial tamponade andinadequate ventricular filling (Class IIb, LOE C). 155–162 Minimizeinterruption of CPR while performing echocardiography.End-Tidal CO 2 (PETCO 2 )Continuous capnography or capnometry monitoring, if available,may be beneficial during CPR, to help guide therapy,especially the effectiveness of chest compressions (Class IIa,LOE C). Animal and adult studies show a strong correlationbetween PETCO 2 and interventions that increase cardiac outputduring CPR or shock. 53,163–169 If the PETCO 2 is consistently10 to 15 mm Hg, focus efforts on improving chest compressionsand make sure that the victim does not receiveexcessive ventilation. An abrupt and sustained rise in PETCO 2in adults 170,171 and animals 110 is observed just prior to clinicalidentification of ROSC, so use of PETCO 2 may spare therescuer from interrupting chest compressions for a pulsecheck. PETCO 2 must be interpreted with caution for 1 to 2minutes after administration of epinephrine or other vasoconstrictivemedications because these medications may decreasethe end-tidal CO 2 level by reducing pulmonary blood flow.Vascular AccessVascular access is essential for administering medicationsand drawing blood samples. Obtaining peripheral venousaccess can be challenging in infants and children during anemergency; intraosseous (IO) access can be quickly establishedwith minimal complications by providers with variedlevels of training. 172–179 Limit the time spent attempting toestablish peripheral venous access in a critically ill or injuredchild. 180Intraosseous (IO) AccessIO access is a rapid, safe, effective, and acceptable route forvascular access in children, 172–179,181 and it is useful as theinitial vascular access in cases of cardiac arrest (Class I,LOE C). All intravenous medications can be administeredintraosseously, including epinephrine, adenosine, fluids,blood products, 182,183 and catecholamines. 184 Onset of actionand drug levels for most drugs are comparable to venousadministration. 185 IO access can be used to obtain bloodsamples for analysis including for type and cross match andblood gases during CPR, 186 but acid-base analysis is inaccurateafter sodium bicarbonate administration via the IOcannula. 187 Use manual pressure or an infusion pump toadminister viscous drugs or rapid fluid boluses; 188,189 followeach medication with a saline flush to promote entry into thecentral circulation.Venous AccessPeripheral IV access is acceptable during resuscitation if itcan be placed rapidly, but placement may be difficult in acritically ill child. Although a central venous catheter canprovide more secure long-term access, its placement requirestraining and experience, and the procedure can be timeconsuming.Therefore central venous access is not recommendedas the initial route of vascular access during anemergency. If both central and peripheral accesses are available,administer medications into the central circulation sincesome medications (eg, adenosine) are more effective whenadministered closer to the heart, and others (eg, calcium,amiodarone, procainamide, sympathomimetics) may be irritatingwhen infused into a peripheral vein. The length of acentral catheter can contribute to increased resistance, making itmore difficult to push boluses of fluid rapidly through amultilumen central than a peripheral catheter.Endotracheal Drug AdministrationVascular access (IO or IV) is the preferred method for drugdelivery during CPR, but if it is not possible, lipid-solubledrugs, such as lidocaine, epinephrine, atropine, and naloxone(mnemonic “LEAN”) 190,191 can be administered via an endotrachealtube. 192 However, the effects may not be uniformwith tracheal as compared with intravenous administration.One study of children in cardiac arrest 193 demonstratedsimilar ROSC and survival rates regardless of the method ofDownloaded from circ.ahajournals.org by on October 20, 2010
Page 3 and 4: Kleinman et al Part 14: Pediatric A
Page 5: Kleinman et al Part 14: Pediatric A
Page 19: Kleinman et al Part 14: Pediatric A
Page 24 and 25: S898 Circulation November 2, 201046
Page 30 and 31: S904 Circulation November 2, 2010re
Page 34: S908 Circulation November 2, 201048

pediatric-ALS-AHA-guidelines-circulation_11-2010 - SSM Cardinal ...

Create successful ePaper yourself

Delete template?

Save as template?