1. Pediatric Resuscitation
Russian Field Hospital
Nias, Indonesia
4/05

2. Lecture Objectives The goal of this module:
Perform rapid cardiopulmonary assessment
Recognize signs of respiratory distress, respiratory failure, and shock
Slide 2: Lecture Objectives
The goals of this lecture are to help participants learn to
Perform a rapid cardiopulmonary assessment
Recognize signs of respiratory distress, respiratory failure, and shock
Each participant should practice rapid cardiopulmonary assessment during the scenario practice stations and should be prepared to demonstrate it during the practical evaluation.

3. Progression of Respiratory Failure and Shock
Various Conditions
Respiratory failure
Shock
Optional
Slide 3: Progression of Respiratory Failure and Shock to
Cardiopulmonary Failure and Arrest
In infants and children a variety of conditions (such as airway obstruction, trauma, toxic ingestion, or sepsis) may ultimately cause cardiopulmonary failure and cardiopulmonary arrest.
These conditions typically produce either respiratory failure, shock, or a combination of the two and can lead to cardiopulmonary failure if not promptly and adequately treated.
Cardiopulmonary failure
Cardiopulmonary arrest

4. Comparison of Survival
100%
Survival rate
50%
Optional
Slide 4: Survival Following Respiratory Arrest vs
Cardiopulmonary Arrest in Children
Respiratory and cardiac arrest are both life-threatening events requiring resuscitation.
But good outcome of resuscitation (survival to hospital discharge) is more likely following respiratory arrest than cardiopulmonary/cardiac arrest.
Respiratory arrest often precedes cardiac arrest in infants and children. If respiratory arrest is recognized early and treated appropriately, cardiac arrest can be prevented and the likelihood of recovery increased. 0%
Respiratory arrest
Cardiopulmonary arrest

5. Rapid Cardiopulmonary Assessment
1. Evaluation of general appearance (mental status, tone, responsiveness)
2. Physical examination of airway, breathing, and circulation (ABCs)
3. Classification of physiologic status
Slide 5: Elements of Rapid Cardiopulmonary Assessment
Rapid cardiopulmonary assessment begins with an evaluation of the child’s general appearance, including mental status, muscle tone and position, and response to any stimulation (such as your approach, parents, voice, or painful procedures).
The physical examination component of rapid cardiopulmonary assessment focuses on airway, breathing, and circulation to identify respiratory distress, respiratory failure, or shock.
Classification of physiologic status occurs after assessment when you determine the severity of the patient’s respiratory or cardiovascular dysfunction.
This physical examination and classification should be accomplished in less than 30 seconds.
Rapid cardiopulmonary assessment should be accomplished in less than 30 seconds!

6. Pediatric Assessment Triangle

7. General Appearance

8. Evaluation of General Appearance
General color (“looks good” vs “looks bad”)
Mental status, responsiveness
Activity, movement,
muscle tone
Age-appropriate response
Slide 6: Evaluation of General Appearance
From the moment of the initial encounter with the infant or child the PALS provider should begin to form an opinion about the degree of distress the child demonstrates: is this an emergency or can the child wait for a more detailed assessment?
Evaluation of general appearance can become instinctive and takes into account the child’s
General color
Apparent mental status and responsiveness
Activity, movement, and muscle tone
Watch for age-appropriate behaviors (eg, resistance to separation from the primary caretaker and “stranger anxiety” in the toddler).
Remember: a decreased response to painful stimulus is abnormal in a child of any age.

9. Breathing Evaluation

10. Physical Examination: Airway
Clear
Maintainable
Not maintainable
without intubation
Slide 7: Physical Examination of the Airway
The participant should evaluate the child’s airway and determine if
intervention is required. The following terms can be helpful in
determining the need for airway support:
Clear means that no airway assistance or protection is necessary.
Maintainable means that noninvasive assistance is necessary to ensure airway patency (head position, suctioning, bag-mask ventilation), but invasive intervention is not required.
Not maintainable means that invasive intervention is necessary to maintain airway patency (eg, tracheal intubation, needle cricothy-rotomy, relief of foreign-body obstruction).

11. Evaluating Respirations
Respiratory rate
Respiratory effort (work of breathing)
Breath sounds/air entry/tidal volume
STRIDOR (inspiration)
WHEEZE (expiration)
Skin color and pulse oximetry
Slide 8: Physical Examination of Breathing
To assess the effectiveness of breathing you should evaluate the
following:
Rate: Should be appropriate for the child’s clinical condition.
Tachypnea is a nonspecific sign of distress. A respiratory rate of more than 60 breaths per minute, however, is abnormal in all age groups.
A slow or irregular respiratory rate in an acutely ill or injured infant or child is ominous because it often indicates that respiratory arrest is imminent.
Effort: Relates to the work of breathing and breathing mechanics.
Air entry/tidal volume: Determined by observation of chest expansion and auscultation over central and peripheral lung fields.
Inspiratory stridor suggests croup or the presence of a foreign body.
Wheezing or a prolonged expiratory phase suggests asthma or bronchiolitis.
Skin color: Pink skin and mucous membranes suggest good oxygena-tion; cyanosis suggests hypoxemia. Pulse oximetry can quantify oxygen saturation.

12. Rapid Cardiopulmonary Assessment: Classification of Status
Respiratory distress: Increased work of breathing
Respiratory failure: Inadequate oxygenation or ventilation
Slide 9: Rapid Cardiopulmonary Assessment: Classification of
Physiologic Status
Rapid cardiopulmonary assessment allows classification of the patient’s respiratory status.
Respiratory distress is characterized by increased effort/increased work of breathing.
Respiratory failure indicates the presence of inadequate pulmonary gas exchange, resulting in inadequate oxygenation or ventilation. Note that respiratory failure may be present with or without respiratory distress.

13. Cardiovascular Assessment

14. Cardiovascular Variables Affecting Systemic Perfusion
Preload
Myocardial contractility
Afterload
Stroke volume
Heart rate
Cardiac output
Systemic vascular resistance
Slide 10: Cardiovascular Variables Affecting Systemic Perfusion
This graphic illustrates the relationship of cardiovascular variables that affect cardiac output and systemic perfusion. Note that one goal of PALS is to support cardiac output (the amount of blood delivered to the tissues each minute) that is adequate to meet tissue oxygen demand.
Although many variables influence cardiac output and oxygen delivery, the only variables readily measured in the clinical setting are the child’s heart rate and blood pressure. Note that blood pressure can be maintained despite a fall in cardiac output if systemic vascular resistance increases. This explains how children can have a normal blood pressure despite the presence of shock (compensated shock).
If cardiac output is inadequate, we attempt to improve it through support of an optimal heart rate and stroke volume. Stroke volume is supported through manipulation of cardiac preload, contractility, and afterload.
Blood pressure

15. Response to Shock 140 100 60 Percent of control 20 Compensated
Vascular resistance
Percent of control
Slide 11: Hemodynamic Response to Shock in Infants and Children
This figure illustrates typical changes in heart rate, blood pressure, and cardiac output as the child moves from compensated to decompensated (ie, hypovolemic to hypotensive) shock.
Note that tachycardia without hypotension is present in compensated shock. Blood pressure is initially maintained through an increase in systemic vascular resistance.
As cardiac output falls further, blood pressure begins to fall, and shock is characterized as decompensated shock.
Cardiac output
Blood pressure
Compensated
shock
Decompensated
shock

16. Decompensated Shock
Compensatory mechanisms fail to maintain adequate cardiac output and blood pressure
Slide 12: Decompensated Shock Is Characterized by Hypotension
Shock is characterized by cardiac output that is inadequate to meet the metabolic demands of the body. Cardiac output may be high, normal, or low, but in all cases of shock, cardiac output is inadequate to meet metabolic needs.
When shock is present the child’s blood pressure may be high, normal, or low.
Initially the child in shock may demonstrate a normal blood pressure. At this point the shock is characterized as compensated shock.
Hypotension often develops only as a late sign of shock. Once hypotension develops, shock is characterized as decompen-sated shock.

17. Physical Examination: Circulation
Cardiovascular function
Heart rate
Pulses, capillary refill
Blood pressure
End-organ function/perfusion
Brain
Skin
Kidneys
Slide 13: Physical Examination of the Circulation
Cardiovascular assessment begins with an evaluation of the child’s responsiveness—if the child is unresponsive, urgent intervention is required. Then you begin direct assessment of the cardiovascular system, including evaluation of heart rate, quality of proximal and distal pulses, and blood pressure.
Indirect assessment of the cardiovascular system is discussed later and includes evaluation of signs of end-organ function to evaluate end-organ perfusion.
End-organ function includes function of the brain, skin, and kidneys.
You will evaluate indirect signs of brain and skin perfusion during the cardiovascular assessment.
A compromise in end-organ function may indicate that cardiac output and end-organ perfusion are inadequate.

18. Physical Examination: Circulation
Typical Assessment Order:
Observe mental status
Feel for heart rate, pulse quality, skin temperature, capillary refill
Measure blood pressure
(Measure urine output later)
Slide 14: Physical Examination of the Circulation—Typical
Assessment Order
This slide describes the typical order of the rapid assessment of the circulation.
Early measurement of blood pressure and later measurement of urine output indicate that blood pressure should be quantified quickly, although a precise quantitative measurement is not necessary to identify the presence of shock. Measurement of urine output requires an invasive procedure that should be completed after initial interventions.

19. Physical Examination: Circulation
Evaluation of responsiveness
A — Awake
V — responsive to Voice
P — responsive to Pain
U — Unresponsive
Slide 15: Physical Examination of the Circulation—Evaluation of
Responsiveness
Indirect assessment: Evaluation of responsiveness may provide
important information about cerebral perfusion.
The AVPU assessment is used to describe the level of responsiveness as a simple, reproducible method of evaluating and tracking the child’s level of consciousness (reflecting brain perfusion).
The child’s responsiveness and level of consciousness will deteriorate as cerebral perfusion deteriorates.
Note: If the level of consciousness/responsiveness has deteriorated, the
healthcare provider should be prepared to rule out primary neurologic
disease or injury but should also suspect a compromise in
cardiorespiratory function.

20. Heart Rates in Children
Infant
Normal
Compensating?
SVT
Child
Slide 16: Typical Ranges of Heart Rates in Children
The heart rate in infants and children normally varies with age and
activity.
The “normal” range of heart rate decreases as the child ages.
Heart rate must be evaluated in the context of the patient’s clinical condition. Heart rate increases with fever, anxiety, pain, or shock.
A healthy, screaming 6-year-old child may have a heart rate of 130 bpm.
The same heart rate of 130 bpm in a quiet 6-year-old child may be evidence of shock.
Increased heart rate (tachycardia) may be a nonspecific sign of cardiorespiratory distress.
Heart rate ranges for normal sinus rhythm, sinus tachycardia, and supraventricular tachycardia (SVT) overlap, as depicted in the slide.
The diagnosis of SVT should always be considered when the heart rate is more than 220 bpm in an infant and more than 180 bpm in a child.
Normal
Compensating?
SVT

21. Physical Examination: Circulation
Evaluation of skin perfusion
Temperature of extremities
Capillary refill
Color
Pink
Pale
Blue
Mottled
Slide 17: Physical Examination of the Circulation—Evaluation of
Skin Perfusion
Indirect assessment: Evaluation of skin perfusion may provide
important information about cardiac output.
Skin perfusion may be compromised early in some forms of shock (eg, hypovolemic and cardiogenic shock) that result in redistribution of blood flow away from the skin and toward vital organs (brain, heart).
Pulses: Peripheral pulses may be diminished if stroke volume is decreased or peripheral vasoconstriction is present.
Temperature: Cool extremities suggest inadequate cardiac output or cold ambient temperature.
Capillary refill: Normal capillary refill time should be less than 2 seconds if the ambient temperature is warm.
Color can change with changes in perfusion/oxygen delivery:
Pink color of mucous membranes indicates normal perfusion.
Pale color may indicate ischemia, anemia, or cold environment.
Blue color (cyanosis) indicates hypoxemia or inadequate perfusion with pooling of blood flow or increased oxygen extraction in the skin.
Mottled color may be caused by a combination of the above.
With distributive shock (eg, septic shock) skin perfusion may be normal or adequate.

22. Palpation of Central and Distal Pulses
Slide 18: Palpation of Central and Distal Pulses
Evaluation of pulses and distal perfusion is part of the direct
cardiovascular assessment.
Palpation of central and peripheral pulses provides important information for the cardiovascular examination:
Palpation of pulses can be used to evaluate heart rate and some indirect evidence of stroke volume and systemic vascular resistance.
Pulse quality reflects the adequacy of peripheral perfusion.
Weak or absent pulses may indicate poor stroke volume, increased systemic vascular resistance, or both.
Loss of perfusion in hands and feet often precedes hypotension and critical loss of vital organ perfusion in shock.
Hypotension often develops before loss of central pulses.

23. Prolonged capillary refill (10 seconds) in a
3-month-old with shock
Slide 19: Evaluation of Capillary Refill
These 2 photos of the foot demonstrate a capillary refill time of 10 seconds in a 3-month-old infant in cardiogenic shock with a systolic blood pressure of 90 mm Hg 1 hour before death.
To evaluate capillary refill, elevate the extremity above the level of the heart to ensure that arterial (not venous) perfusion is being evaluated.
Note: Capillary refill can also be prolonged in cold ambient tempera-
tures or hypothermia.

24. Physical Examination: Circulation
Estimate of Minimum Systolic Blood Pressure
Age Minimum systolic blood pressure (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
Slide 20: Physical Examination of the Circulation—Estimate of
Minimum Systolic Blood Pressure Ranges in Infants and Children
Lower-limit (5th percentile) systolic pressures are estimated in children 1 to 10 years of age, using the following formula:
70 mm Hg + (2 x age in years) = 5th percentile systolic BP
Note that children older than 10 years should have a systolic blood pressure of at least 90 mm Hg.
Blood pressures lower than the recommended ranges are usually inadequate.
Remember: A child may demonstrate signs of shock despite a “normal” blood pressure (this is compensated shock). The presence of a blood pressure lower than the minimum systolic blood pressure range for the child’s age indicates hypotension and the presence of decompensated shock.

25. Minimum Systolic BP by age (5% of the range of normal)

26. Physical Examination: Circulation
Cardiovascular function
Heart rate
Pulses, capillary refill
Blood pressure
End-organ function/perfusion
Brain (Mental Status)
Skin (Capillary Refill Time)
Kidneys
Slide 21: Physical Examination of the Circulation—Indirect
Assessment by Evaluation of End-Organ Function and Perfusion
Once you have completed assessment of mental status and direct assessment of the cardiovascular system (heart rate, quality of proximal and distal pulses, and blood pressure), you are ready to perform indirect assessment by evaluating end-organ perfusion.
Indirect assessment of the cardiovascular system includes evaluation of signs of end-organ function to evaluate end-organ perfusion.
You have already evaluated general brain function in your initial evaluation of the patient’s mental status.
You have already evaluated skin perfusion in your evaluation of the patient’s pulses and capillary refill.
A compromise in end-organ function may indicate that cardiac output and end-organ perfusion are inadequate.

27. Physical Examination: Circulation
Evaluation of End-Organ Perfusion
Kidneys
Urine Output
Normal: 1 to 2 mL/kg per hour
Initial measurement of urine in bladder not helpful
Slide 22: Evaluation of End-Organ Perfusion—Kidneys
Normal urine output is expected if the infant or child is well hydrated and well perfused with good renal function.
A decrease in “normal” urine output may indicate inadequate renal perfusion (caused by dehydration or low cardiac output) or a compromise in renal function.
Urine output decreases as renal perfusion decreases.
When a bladder catheter is first inserted, the initial measurement of urine output is often not helpful because the volume of urine in the bladder accumulated over an unknown period of time. Once a urinary catheter is inserted, you can evaluate urine volume on an hourly basis.

28. Classification of Physiologic Status: Shock
Early signs (compensated)
Increased heart rate
Poor systemic perfusion
Late signs (decompensated)
Weak central pulses
Altered mental status
Hypotension
Slide 23: Classification of Physiologic Status—Shock
Once you have examined the child’s circulatory function, you should be able to determine if the child is in shock and to further classify the shock as compensated or decompensated.
A major goal of the PALS Provider Course is to ensure that participants are able to recognize and manage compensated shock to prevent the development of decompensated shock and cardiac arrest.
Early signs of compensated shock include tachycardia (a nonspecific sign) and evidence of poor systemic perfusion (reviewed in slide 21)
Hypotension is a critical sign of decompensation that is typically accompanied by weak central pulses and altered mental status.

29. Septic Shock Is Different
Cardiac output may be variable
Perfusion may be high, normal, or low
Early signs of sepsis/septic shock include
Fever or hypothermia
Tachycardia and tachypnea
Leukocytosis, leukopenia, or increased bands
Slide 24: Septic Shock Is Unique —Signs of Septic Shock Differ
From Hypovolemic and Cardiogenic Shock
In septic shock the patient’s calculated cardiac output may be normal, increased, or decreased.
In hypovolemic and cardiogenic shock, cardiac output is redistributed (diverted away from the skin, intestines, and kidneys) to maintain flow to the brain and heart. In septic shock blood flow is maldistributed so that some tissue beds (typically including the skin) receive excellent blood flow whereas others receive inadequate blood flow. Hypotension may be present despite skin perfusion that appears to be good.
Early signs of septic shock include fever or hypothermia plus tachy-cardia and tachypnea. The number of white blood cells may be increased (leukocytosis) or severely decreased (leukopenia), and the number of immature (band) forms of white blood cells is increased.

30. Special Situations: Trauma
Airway and Breathing problems are more common than Circulatory shock
Use the ABC or assessment triangle approach plus
Airway + cervical spine immobilization
Breathing + pneumothorax management
Circulation + control of bleeding
Identify and treat life-threatening injuries
Slide 25: Special Situations—Trauma
Trauma, one cause of shock, is often complicated by airway obstruc-tion, respiratory failure, and life-threatening injuries. Compromised airway and ventilation are often more important early abnormalities than hypovolemic shock.
Clinical assessment and treatment of the trauma patient requires use of the PALS ABC approach with the following modifications:
Cervical spine immobilization is required while opening the airway and during any airway interventions.
Support of breathing and ventilation requires identification of life-threatening chest injuries and respiratory problems such as tension pneumothorax, particularly if the patient does not respond to initial support.
Support of circulation requires control of bleeding.
Throughout stabilization of the trauma victim the rescuer must identify and treat life-threatening injuries (eg, abdominal hemorrhage, cardiac tamponade, tension pneumothorax).

31. Special Situations: Trauma
Spinal Precautions?
Pneumothorax?
Slide 25: Special Situations—Trauma
Trauma, one cause of shock, is often complicated by airway obstruc-tion, respiratory failure, and life-threatening injuries. Compromised airway and ventilation are often more important early abnormalities than hypovolemic shock.
Clinical assessment and treatment of the trauma patient requires use of the PALS ABC approach with the following modifications:
Cervical spine immobilization is required while opening the airway and during any airway interventions.
Support of breathing and ventilation requires identification of life-threatening chest injuries and respiratory problems such as tension pneumothorax, particularly if the patient does not respond to initial support.
Support of circulation requires control of bleeding.
Throughout stabilization of the trauma victim the rescuer must identify and treat life-threatening injuries (eg, abdominal hemorrhage, cardiac tamponade, tension pneumothorax).
Bleeding control?

32. Special Situations: Toxicology
Airway obstruction, Breathing depression, and Circulatory dysfunction may be present
Use the ABC and assessment triangle approach, plus watch for
Airway: reduced airway protective mechanisms
Breathing: respiratory depression
Circulation: arrhythmias, hypotension, coronary ischemia
Identify and treat reversible complications
Administer antidotes
Slide 26: Special Situations—Toxicology
Ingestion of drugs may cause a depressed level of consciousness with airway obstruction and respiratory depression. Life-threatening arrhythmias, vasodilation and hypotension, and coronary ischemia may also develop.
Clinical assessment and treatment of toxicology patients requires use of the PALS ABC approach with the following modifications:
Airway: Support a patent airway.
Breathing: Support breathing if respiratory depression is present or developing.
Circulation: Support of circulation requires identification and treatment of life-threatening arrhythmias, support of vascular tone and treatment of hypotension, and identification of coronary ischemia.
During stabilization of the toxicology victim the rescuer must identify and treat potentially reversible causes of deterioration, such as acidosis, electrolyte imbalance, arrhythmias, and vasodilation with hypotension.
Administer antidotes if available (calcium for calcium channel blocker overdose, Fab antibody fragments for digoxin, or naloxone for narcotics).

33. Special Situations: Toxicology
Is the Patient Awake enough to maintain airway?
Respiratory Effort and Rate?
Slide 26: Special Situations—Toxicology
Ingestion of drugs may cause a depressed level of consciousness with airway obstruction and respiratory depression. Life-threatening arrhythmias, vasodilation and hypotension, and coronary ischemia may also develop.
Clinical assessment and treatment of toxicology patients requires use of the PALS ABC approach with the following modifications:
Airway: Support a patent airway.
Breathing: Support breathing if respiratory depression is present or developing.
Circulation: Support of circulation requires identification and treatment of life-threatening arrhythmias, support of vascular tone and treatment of hypotension, and identification of coronary ischemia.
During stabilization of the toxicology victim the rescuer must identify and treat potentially reversible causes of deterioration, such as acidosis, electrolyte imbalance, arrhythmias, and vasodilation with hypotension.
Administer antidotes if available (calcium for calcium channel blocker overdose, Fab antibody fragments for digoxin, or naloxone for narcotics).
Arrythmias?
Vascular Tone?
Ischemia?

34. Classification of Physiologic Status: Cardiopulmonary Failure
Cardiopulmonary failure produces signs of
respiratory failure and shock:
Agonal respirations
Bradycardia
Cyanosis and poor perfusion
Slide 27: Classification of Physiologic Status—Cardiopulmonary
Failure
The preceding discussion separated the physical examination and physiologic assessment of respiratory failure and shock as if they were unrelated.
But late respiratory failure and decompensated (late) shock can ultimately result in cardiopulmonary failure.
The clinical characteristics of cardiopulmonary failure may not allow identification of the primary problem (cardiovascular vs respiratory).

35. Classification of Cardiopulmonary Physiologic Status
Stable
Respiratory distress
Respiratory failure
Shock
Compensated
Decompensated
Cardiopulmonary failure
Slide 28: Classification of Cardiopulmonary Physiologic Status
The ABC-focused physical examination during rapid cardiopulmonary assessment enables rapid classification of cardiopulmonary physiologic status, which guides initial management.

37. Rapid Cardiopulmonary Assessment: Summary
Evaluate general appearance
Assess ABCs
Classify physiologic status
Respiratory distress
Respiratory failure
Compensated shock
Decompensated shock
Cardiopulmonary failure
Begin management: support ABCs
Slide 29: Rapid Cardiopulmonary Assessment — Summary
Each PALS provider must be able to perform a rapid cardiopulmonary assessment within a few seconds:
Evaluate general appearance (determine urgency of condition).
Perform a targeted physical examination to assess Airway, Breathing, and Circulation.
Classify physiologic status.
On the basis of the patient’s physiologic status, begin a management plan to support the ABCs and begin appropriate interventions.

38. Checkpoint Rapidly perform assessment
Use the information to prioritize your resuscitation efforts
Remember the Pediatric Assessment Triangle as we practice cases

39. Rapid Cardiopulmonary Assessment Application
A 3-week-old infant arrives in the ED:
CC: Severe vomiting and diarrhea
Physical exam: Gasping respirations, bradycardia, cyanosis, and poor perfusion
What ar the results of your RAPID ASSESSMENT?
What is the PHYSIOLOGIC STATUS?
What are the emergency interventions?
Slide 30: Rapid Cardiopulmonary Assessment—Application
A 3-week-old infant arrives in the ED. The infant has vomiting and diarrhea, symptoms of gasping respirations, and poor perfusion.
What is the patient’s physiologic status?
Cardiorespiratory failure
What are the initial interventions?
Open the airway and assist ventilation while delivering oxygen.
Monitor heart rate.
Assess the patient’s response, particularly noting changes in heart rate, color, and respiratory effort.
Evaluate oxygenation with pulse oximetry if available.
Establish vascular access rapidly.

40. What is this Child’s Assessment?

41. Rapid Cardiopulmonary Assessment Application
Case Progression
Response to intubation and ventilation with 100% oxygen:
Heart rate: 180 bpm
Blood pressure: 50 mm Hg systolic
Pink centrally, cyanotic peripherally
No peripheral pulses
No response to painful stimuli
What is happening?
What is next treatment step?
Slide 31: Case Progression
The infant has been tracheally intubated and is being ventilated with FiO2 of 1.00.
Clinical signs are as described in the slide.
What is the child’s physiologic status now?
Answer: Decompensated shock
What are your next priorities?
Obtain vascular access rapidly if this has not been achieved.
Provide rapid fluid bolus, 20 mL/kg NS or lactated Ringer’s.

43. Rapid Cardiopulmonary Assessment Application: Response to Therapy
Vital signs improved
Slide 32: Response to Therapy
The infant’s heart rate decreases slightly, and oxygenation improves with assisted ventilation.
What intervention would be appropriate now?
Answer: Administer another rapid fluid bolus, then reassess.
Note: This infant had ongoing fluid losses due to diarrhea and required
administration of more than 100 mL/kg during the first 4 hours of
resuscitation.

44. Andrew Garrett, MD Division of Transport and Emergency Medicine
Pediatric Intubation
Andrew Garrett, MD
Division of Transport and Emergency Medicine

45. Goals Review of some basic concepts of pediatric airway management
Introduce/review RSI in a stress-free environment
Have a chance to practice intubation skills later today

46. Review and Overview of Airway Management
Children at higher risk for hypoxia and respiratory failure:
Anatomic differences
Higher metabolic rate
Ambiguous symptoms of hypoxia
Head trauma is common in pediatrics
Limited practice of management skills

47. Airway Anatomic Differences (Extrathoracic)
Relatively larger tongue
Tongue placed superiorly (C3-4)
Angle of epiglottis angled away from larynx
Vocal folds can trap ET tube
Narrowest area at cricoid vs. glottis

48. Anatomy
epiglottis
True VC
False VC
cartilage
trachea
esophagus

49. Cricoid Cartilage

50. Airway Anatomic Differences (Intrathoracic)
Compliance of conducting airways at high flow rates
Fewer, smaller alveoli (< 8 yrs)
Smaller FRC (functional reserve)
Decreased diffusion
Metabolic Rate
2 x adult oxygen consumption rate
Shorter tolerance of apnea

51. Can your patient be managed without intubation?
The A of the ABC’s
Chin lift
Jaw thrust
Suction
Oropharyngeal airway
Nasopharyngeal airway

52. Intubation Overview Positioning Choose the tube size
Choose the blade size and type
Insertion distance
Sedation
Paralysis
Equipment

53. Positioning the Patient
Alignment of the 3 axis
Oropharynx, Pharynx, Trachea O P T

54. Positioning thoughts Don’t rush this part…
Be careful of cervical spine injury
Infant
Large occiput, gentle lift of shoulder
Use a folded towel
Adolescents and Adults
Extension of head on a towel support

55. Proper alignment for intubation (almost…)

56. Tube Size Cuffed vs. Uncuffed (age cutoff ~8 yrs)
Remember pediatric airway anatomy
( Age + 4 ) / 4 for > 1 year old
3.5 for newborn
2.5 for preemie (< 28 weeks)
3 for in between

57. Choose your blade Macintosh
Into the vallecula, lift the epiglottis from its foundation to visualize the trachea
Miller
Past the epiglottis, directly lift the epiglottis with traction to visualize

58. Macintosh vs. Miller 2 3 Preemie Neonate <2 yrs 2-6 yrs 6-12 yrs1
1.5 2 3

59. Insertion Distance < 4 kg weight (kg) + 6 *
Guidelines:
< 4 kg weight (kg) + 6 *
>4 kg 3 x ET tube size
Distance to mandibular ridge
* usually a slightly high position

60. Confirmation of Placement
Auscultation
Capnography
Radiography
Visualization

61. The Technique of R.S.I. Keep it simple, not stressful In a nutshell:
What drug has been proven to increase the chance of successfully performing endotracheal intubation?

62. The Technique of R.S.I. Keep it simple, not stressful In a nutshell:
What drug has been proven to increase the chance of successfully performing endotracheal intubation?
A paralytic agent such as succinylcholine

63. The Technique of R.S.I.
Therefore, all RSI consists of is using a paralytic to increase the chance of being successful

64. The Technique of R.S.I.
Therefore, all RSI consists of is using a paralytic to increase the chance of being successful
The rest of the drugs are because we’re nice (but that’s optional!)
SEDATIVE

65. The Technique of R.S.I.
Therefore, all RSI consists of is using a paralytic to increase the chance of being successful
The rest of the drugs are because we’re nice (but that’s optional!)
SEDATIVE
Etomidate, benzos, propofol, etc.
Serves to make it a more pleasant experience
Don’t need to duplicate efforts

66. The Technique of R.S.I.
Therefore, all RSI consists of is using a paralytic to increase the chance of being successful
Or because we think they should help prevent a side effect

67. The Technique of R.S.I.
Therefore, all RSI consists of is using a paralytic to increase the chance of being successful
Or because we think they should help prevent a side effect
ATROPINE

68. The Technique of R.S.I.
Therefore, all RSI consists of is using a paralytic to increase the chance of being successful
Or because we think they should help prevent a side effect
ATROPINE
Dryer work environment
Heart rate stabilization

69. The Technique of R.S.I.
Therefore, all RSI consists of is using a paralytic to increase the chance of being successful
Or because we think they should help prevent a side effect
LIDOCAINE *

70. The Technique of R.S.I.
Therefore, all RSI consists of is using a paralytic to increase the chance of being successful
Or because we think they should help prevent a side effect
LIDOCAINE *
A bit questionable
May help prevent ICP increase

71. The Technique of R.S.I. Don’t forget the basics though: BVM skills
Positioning
Preparedness
Don’t rush, RSI is not a rescue airway technique, use BVM until you are ready

72. RSI: Rapid Sequence Intubation
“full stomach rule” in urgent intubations
Preoxygenation 1-5 minutes with 100%
Utilize Sellick maneuver
Choreography of medications
Confidence of providers to adequately ventilate after medications are given.
Rule out airway compression from mass effect if paralysis is being considered.

73. Sedation * can be tripled for IM dosing Fentanyl 1-2 mcg/kg IV
Midazolam 0.1 mg/kg IV
Diazepam 0.1 mg/kg IV
Ketamine* mg/kg IV
* can be tripled for IM dosing

74. Paralysis * can be doubled for IM dosing
Succinylcholine * 1-2 mg/kg IV
5 to 10 min
Rocuronium mg/kg IV
~30-45 minutes
Pancuronium 0.1 mg/kg IV
~1-2 hours
Vecuronium 0.1 mg/kg IV
~30 minutes
* can be doubled for IM dosing

75. Plans B and C? After deciding to undertake RSI
Make sure you have a backup/failed airway plan
LMA
Combitube
Fiberoptic, Bougie, Digital
The final option
Surgical airway
Percutaneous or Open

76. Equipment and Technique
Take a moment to double check your equipment and medications before you start

77. The flow of things Examination (esp. neuro status, etc.)
Equipment checklist
Preoxygenate
Sedate, Paralyze, Intubate, Secure
Confirm placement
Continuous evaluation of placement

78. Tips from the Field: Know the size and depth of the tube
Confirm placement with every move
Tape tape tape!
When in doubt, take it out and bag!
Don’t forget the CXR
Check your battery and bulb

79. Ready to Intubate?
Ideal circumstances!
Reality!

80. Circulation After the RAPID ASSESSMENT is done
After BREATHING interventions are started
Priorities
STOP major bleeding
Get IV access
IV, IO, umbilical vein
We will review techniques

81. Circulation Priorities IV Fluids Preload, afterload
Saline 20 mL per kg
Give it fast
Repeat assessments and vital signs
Repeat if necessary
Consider blood?

82. IV Fluids Preload Myocardial contractility Afterload Stroke volume
Heart rate
Cardiac output
Systemic vascular resistance
Slide 10: Cardiovascular Variables Affecting Systemic Perfusion
This graphic illustrates the relationship of cardiovascular variables that affect cardiac output and systemic perfusion. Note that one goal of PALS is to support cardiac output (the amount of blood delivered to the tissues each minute) that is adequate to meet tissue oxygen demand.
Although many variables influence cardiac output and oxygen delivery, the only variables readily measured in the clinical setting are the child’s heart rate and blood pressure. Note that blood pressure can be maintained despite a fall in cardiac output if systemic vascular resistance increases. This explains how children can have a normal blood pressure despite the presence of shock (compensated shock).
If cardiac output is inadequate, we attempt to improve it through support of an optimal heart rate and stroke volume. Stroke volume is supported through manipulation of cardiac preload, contractility, and afterload.
Blood pressure

83. Cardiovascular Cases

84. Objectives Differentiate shock from hypotension
Distinguish compensated from decompensated shock
Outline appropriate shock management
Identify and manage selected pediatric dysrhythmias 2

85. Shock and Hypotension
Shock is inadequate perfusion and oxygen delivery.
Hypotension is decreased systolic blood pressure.
Shock can occur with increased, decreased, or normal blood pressure. 22

86. Recognition of Shock Compensated: Decompensated:
Normal level of consciousness
• Altered level of consciousness (ALOC)
• Tachycardia
• Profound tachycardia, or bradycardia
• Normal or delayed perfusion
• Delayed perfusion
• Normal or increased BP
• Hypotension 28

87. Management of Shock Interventions: Open airway
Provide supplemental oxygen
Support ventilation
Shock position
Vascular access/fluid resuscitation
Vasopressor support

88. 9-month-old infant
A 9-month-old presents with 3 days of vomiting, diarrhea and poor oral intake.

89. 9-month-old infant Appearance Work of Breathing Circulation to Skin
Agitated, makes eye contact
Work of Breathing
No retractions or abnormal airway sounds
Circulation to Skin
Pale skin color

90. Initial Assessment Airway - Open and maintainable
Breathing - RR 50 breaths/min, clear lungs, good chest rise
Circulation - HR 180 beats/min; cool, dry, pale skin; CRT 3 seconds
Disability - AVPU=A
Exposure - No sign of trauma, weight 8 kg 11

91. What is this child’s physiologic state?
What are your treatment priorities?

92. Treatment priorities: Provide oxygen, as tolerated
Assessment: Compensated shock, likely due to hypovolemia with viral illness
Treatment priorities:
Provide oxygen, as tolerated
Obtain IV access en route
Provide fluid resuscitation
20 ml/kg of crystalloid, repeat as needed
Tony - note that oftentimes the status of the child improves dramatically with fluid resuscitation - rare that the child needs any additional therapy nor advanced airway management 13

93. 160 ml normal saline infused
HR decreased to 140 beats/min
Patient alert and interactive, receiving second bolus on emergency department arrival

94. 15-month-old child
A previously healthy 15-month-old child presents with 12 hours of fever, 1 hour of lethargy and a “purple” rash.

95. 15-month-old child Appearance Work of Breathing Circulation to Skin
No eye contact, lies still with no spontaneous movement
Work of Breathing
No retractions or abnormal airway sounds
Circulation to Skin
Pale skin color

96. Initial Assessment Airway - Open
Breathing - RR 60 breaths/min, poor chest rise
Circulation - HR 70 beats/min; faint brachial pulse; warm skin; CRT 4 seconds; BP 50 mm Hg/palp
Disability - AVPU=P
Exposure - Purple rash, no sign of trauma, weight 10 kg 7

97. What is your assessment of this patient? What is her problem?8

98. This patient is in decompensated shock.
What are your treatment and transport priorities for this patient?

99. Treatment Priorities Begin BVM ventilation with 100% oxygen.
Fluid resuscitation:
IV/IO access on scene
20 ml/kg of crystalloid, repeat as needed en route
Vasopressor therapy
Tony be sure to emphasize need to fluid resuscitate before beginning pressor agents. We had a discussion on this subject on the conference call - decision made to emphasize that it is difficult to initiate drips such as dopamine for children - consider boluses of epinephrine 1: solution for children in decompensated septic shock after adequate fluid resuscitation 60 mL/kg

100. Patient received 20 ml/kg (200 ml) with no change in level of consciousness, HR or BP.
What are your treatment priorities now?

101. Consider endotracheal intubation
Provide second 20 ml/kg fluid bolus
Vasopressor support

102. 3-year-old toddler Toddler is found cyanotic and unresponsive
Child last seen 1 hour prior to discovery
Open bottle of blood pressure medicine found next to child 14

103. 3-year-old toddler Appearance Work of Breathing Circulation to Skin
No spontaneous activity; unresponsive
Work of Breathing
Gurgling breath sounds
Circulation to Skin
Cyanotic, mottled

104. Initial Assessment Airway - Partial obstruction by tongue
Breathing - RR 15 breaths/min, poor air entry
Circulation - HR 30 beats/min; faint femoral pulse; CRT 3 seconds; BP 50/30 mm Hg
Disability - AVPU=P
Exposure - No sign of trauma 17

105. The monitor shows the following rhythm.
What are your treatment priorities for this patient?

106. Treatment Priorities Open airway BVM ventilation/consider intubation
Chest compressions
IV/IO access on scene
Medications (epinephrine, atropine)
Possible antidote - naloxone
Fluid resuscitation
Check glucose
Rapid transport 19

107. Color, CRT and pulse quality improves.
Patient’s heart rate improved to 70 beats/min with assisted ventilation.
Color, CRT and pulse quality improves.
After BVM, patient’s RR increases to 20 breaths/min, good chest rise
Rapid glucose check 100 mg/dL 20

108. 12-month-old child You arrive at the house of a 12-month-old child.
Mother states the child has a history of heart disease and has been fussy for the last 3 hours.
Mother states the child weighs 10 kg.

109. 12-month-old child Work of Breathing Appearance Circulation to Skin
Mild retractions
Appearance
Alert but agitated
Circulation to Skin
Lips and nailbeds blue

110. On initial assessment, you note clear breath sounds, a RR of 60 breaths/min and a heart rate that is too rapid to count.
What rhythm does the monitor show?

111. How can you distinguish SVT from sinus tachycardia?

112. SVT versus Sinus Tachycardia
SVT (Supraventricular Tachycardia)
Sinus Tachycardia
• Vague history of irritability, poor feeding
• History of fever, vomiting/diarrhea, hemorrhage
• Cardiac monitor: QRS complex narrow; R to R interval regular; no visible P waves
• Cardiac monitor: QRS complex narrow; R to R interval varies; P waves present and upright
• HR > 200 beats/min
• HR < 220 beats/min

113. Treatment Priorities Supplemental oxygen Obtain IV access
Convert rhythm based on hemodynamic stability
Stable: vagal maneuvers or adenosine
Unstable:
IV /IO access obtained - adenosine
No IV/IO and unconscious - synchronized cardioversion

114. Blow-by oxygen administered
IV started
Adenosine 0.1 mg/kg (1mg), given rapid IVP with 5 ml saline flush
Five seconds of asystole, followed by conversion to NSR

115. Conclusion
Cardiovascular compromise in children is often related to respiratory failure, hypovolemia, poisoning or sepsis.
Management priorities for shock include airway management, oxygen and fluid resuscitation.
Treat rhythm disturbances emergently only if signs of respiratory failure or shock are present. 34

116. Advanced Topics

117. Two Thumb–Encircling Hands Technique Preferred
Slide 14: The 2 Thumb–Encircling Hands Technique Is Preferred for Infant 2-Rescuer CPR by Healthcare Providers
This technique is preferred for chest compression in small infants when it is physically feasible and 2 healthcare providers are present.

118. Effective Bag-Mask Ventilation Is an Essential BLS Skill
Use only the amount of force and tidal volume needed to make the chest rise
Avoid excessive volume or pressure
Increased inspiratory time may reduce gastric inflation
Cricoid pressure may reduce gastric inflation
Slide 15: Effective Bag-Mask Ventilation Is an Essential BLS Skill
Bag-mask ventilation is now a required part of the BLS for Healthcare Providers Course and must be mastered by all healthcare providers.
Gastric inflation may develop during rescue breathing and is more likely to develop if excessive force or volume is used. The rescuer should use only the amount of force and tidal volume necessary to cause the chest to rise.
Use a bag with a minimum volume of 450 to 500 mL and be sure the chest rises.
If a longer inspiratory time is used, it may be possible to deliver the tidal volume at low pressure to minimize gastric inflation.
Cricoid pressure can compress the esophagus and reduce gastric inflation:
Cricoid pressure should be used only if the victim is unconscious with no cough or gag reflex and an extra rescuer is available.
Avoid excessive pressure that will compress the trachea and occlude the airway.
Cricoid cartilage
Occluded esophagus
Cervical vertebrae

119. 2-Rescuer Bag-Mask Ventilation
One rescuer uses both hands to open the airway and maintain a tight mask-to-face seal
The second rescuer compresses the manual resuscitator bag and may apply cricoid pressure if appropriate
Both rescuers verify adequate chest expansion
Slide 16: Advanced Airway Skills Station: 2-Rescuer Bag-Mask
Ventilation
Bag-mask ventilation is a key skill emphasized in the advanced airway station.
The student should be able to demonstrate 1- and 2-rescuer bag-mask ventilation.
2-rescuer bag-mask ventilation:
The first rescuer opens the airway with a jaw thrust and maintains a tight mask-to-face seal.
The second rescuer compresses the manual resuscitator bag and may apply cricoid pressure if appropriate.
Both rescuers should verify that ventilations are effective (chest rise is visible).

120. Prehospital Tracheal Intubation vs Bag-Mask Ventilation
Bag-mask ventilation may be as effective as intubation if transport time is short
Tracheal intubation requires training and experience
Confirmation of tracheal tube position strongly recommended
Monitoring of quality improvement important
Slide 19: Prehospital Tracheal Intubation vs Bag-Mask Ventilation
There is no single ideal choice for all prehospital systems.
The choice must be based on the training and skills of the provider, the provider’s ongoing experience in intubation, and the transport interval.
In some EMS systems bag-mask ventilation is as effective as tracheal intubation, particularly if the provider is inexperienced in intubation and the transport time is short.
There must be increased emphasis on training healthcare providers in effective bag-mask ventilation.
Use of tracheal intubation should be selective and requires a well-trained, experienced provider.
Tracheal tube position must be confirmed after placement and during transport (particularly when the patient is moved).
The EMS system must establish a system for monitoring quality improvement to ensure safety and effectiveness.

121. Complications of Prehospital Tracheal Intubation
Successful tracheal intubation rate: 57%
Intubation attempts increased time at the scene by 2 to 3 minutes
Unrecognized tube displacement or misplacement: 8%
Esophageal intubation: 2%
Unrecognized extubation: 6%
Esophageal intubation or unrecognized extubation fatal (for 14 of 15 patients)
Slide 20: Complications of Prehospital Tracheal Intubation
In the Gausche study (JAMA. 2000;283:783) the prehospital tracheal intubation success rate was 57%.
Intubation attempts increased time at the scene by an average of 2 to 3 minutes.
Unrecognized tube misplacement or displacement occurred in 8% of all intubated patients and was associated with a poor outcome.
Tracheal intubation is not a benign procedure and it may be harmful, particularly in the hands of inexperienced providers. Quality improvement monitoring is important for all EMS systems.
For providers who are interested, additional information about this
study is contained on optional slide D.
Gausche. JAMA. 2000;283:783.

122. Confirmation of Tracheal Tube Placement in Pediatric Advanced Life Support
Visualize tube through cords
Assess breath sounds, chest rise bilaterally
Secondary confirmation:
Oxygenation (oximetry)
Exhaled CO2 (capnography)
Slide 21: Confirmation of Tracheal Tube Placement in Pediatric
Advanced Life Support
Primary and secondary confirmation of tube placement are recommended.
You should visualize the tube passing through the cords during the intubation procedure.
Primary confirmation then includes assessment of breath sounds and chest expansion bilaterally. Breath sounds and chest expansion should be equal bilaterally if they were equal before the intubation. Breath sounds should be minimal or absent over the stomach. Mist may be present in the tube. These primary confirmation techniques are important but do not yield definitive proof of tracheal intubation.
Secondary confirmation includes evaluation of oxygenation (using oximetry) and detection of exhaled CO2 (using colorimetry or capnography).
If there is any doubt about tube placement, recheck tube placement with a laryngoscope (attempt to visualize the tube passing through vocal cords).

123. Tube Confirmation
No single confirmation device or examination technique is 100% reliable
Detection of exhaled CO2 is reliable in patients weighing >2 kg with a heart rate
Exhaled CO2 can be helpful in cardiac arrest
Confirmation of tube position is particularly important after intubation and after any patient movement
Slide 24: Secondary Confirmation of Tracheal Tube Position:
Recommendations
No single device is reliable in all circumstances.
Detection of exhaled CO2 is very reliable in patients weighing >2 kg with a perfusing cardiac rhythm, so it is strongly recommended (Class IIa).
When pulmonary blood flow is low (eg, cardiac arrest), exhaled CO2 is specific (ie, when present, it confirms tracheal tube position) but not sensitive (ie, when absent, it does not always indicate nontracheal-esophageal tube placement), but its use is still encouraged (Class IIb).
Confirmation of tube position is particularly important after intubation, during transport, and whenever the patient is moved.

124. Insertion of the Laryngeal Mask Airway in Children
The LMA consists of a tube with a cuffed mask at the distal end.
The LMA is blindly introduced into the pharynx until resistance is met; the cuff is then inflated and ventilation assessed.
Slide 26: Insertion of the LMA in Children
The LMA is an airway adjunct that consists of a tube with a cuffed “balloon” or “mask” at the distal end.
The LMA cuff is deflated and lubricated. The LMA is introduced into the pharynx and advanced blindly until resistance is felt. Resistance indicates the location of the tube in the hypopharynx.
The balloon cuff (“mask”) is then inflated. This seals the hypopharynx so that the central distal opening of the tube (in the center of the “mask” or balloon cuff) opens just above the glottic opening into the trachea. Ventilation is provided through the tube with a manual resuscitator (bag).
LMAs do not protect the airway from aspiration, but aspiration is uncommon with use of the LMA in the operating room, and in adults aspiration is less common than during bag-mask ventilation.
Correct position of the LMA may be difficult to maintain during movement of the patient.
Note: There are several different sizes of LMAs. These sizes do not
match tracheal tube sizes.

125. Use of Laryngeal Mask Airway in Pediatric Advanced Life Support
Extensive experience with pediatric and adult patients in the operating room
An acceptable alternative to intubation of the unresponsive patient when the healthcare provider is trained
Contraindicated if gag reflex intact
Limited data outside the operating room (Class Indeterminate)
Slide 25: Use of Laryngeal Mask Airway in PALS
The laryngeal mask airway (LMA) is used to secure the airway in an unconscious/unresponsive victim (no gag reflex).
LMAs are frequently used in the operating room and provide an effective means of oxygenation and ventilation when placed by rescuers with proper training and supervision.
LMAs are contraindicated if the patient’s gag reflex is intact.

126. Intraosseous Needles Are Recommended for Patients >6 Years of Age
Successful use of intraosseous needles has been documented in older children and adolescents
Devices for adult use are commercially available
“No one should die because of lack of vascular access”
Slide 27: Intraosseous Needles Are Recommended for Patients
>6 Years of Age
Many studies in the 1940s documented successful use of intraosseous needles in adults.
Devices for use in adult victims are now commercially available.
Vascular access is essential during resuscitation, so introsseous access should be considered if IV access cannot be achieved.

127. Drug Therapy for Cardiac Arrest
Epinephrine: the drug of choice
Initial IV/IO dose: 0.01 mg/kg (tracheal: 0.1 mg/kg)
Do not routinely use high-dose (1:1,000) epinephrine
Good at getting heart rates to return
Poor long term outcome
Slide 28: Drug Therapy for Cardiac Arrest
Epinephrine remains the drug of choice for treatment of cardiac arrest:
The initial IV/IO dose remains 0.01 mg/kg (0.1 mL/kg of 1:10,000 solution). The tracheal dose remains 0.1 mg/kg (0.1 mL/kg of 1:1,000 solution).
Routine use of high-dose epinephrine is not recommended but may be considered for some conditions, such as sepsis, anaphylaxis, or -blocker overdose.
Vasopressin is recommended as an alternative to epinephrine for adult victims. Vasopressin, however, does not appear to be as effective for asphyxial cardiac arrest, and there is insufficient evidence to recommend its use in infants and children (Indeterminate).

128. Resuscitation of the Newly Born Outside the Delivery Room
Priority: Establish effective ventilation
Provide chest compressions if heart rate is <60 bpm despite adequate ventilation with 100% oxygen for 30 seconds
If meconium is observed in amniotic fluid:
Deliver head and suction pharynx (all infants)
If infant is vigorous, no direct tracheal suctioning
If respirations are depressed or absent, poor tone, or HR <100 bpm, suction trachea directly
Slide 38: Resuscitation of the Newly Born Outside the Delivery
Room
Establishment of ventilation remains the primary goal of care of the depressed newly born who fails to respond to the initial interventions of warming, positioning, drying, and stimulation.
Chest compressions should be provided if heart rate is <60 bpm despite adequate ventilation with 100% oxygen for 30 seconds.
Management of the infant with meconium has been modified: the pharynx should still be suctioned as soon as the head is delivered. If the infant is vigorous on delivery, however, there is no evidence that elective tracheal suctioning is helpful. Direct suction of the trachea is still recommended if the meconium-stained infant has absent or depressed respirations, decreased tone, or a heart rate of <100 bpm.
Compression-ventilation rates and ratios are unchanged.
Compression depth should be to approximately one third the depth of the chest.
Administration of epinephrine is recommended if the heart rate is <60 bpm after a minimum of 30 seconds of adequate ventilation and chest compressions.
If volume expansion is needed, the fluid of choice is isotonic crystalloid.
Note that tracheal doses of epinephrine for the premature or newly born remain unchanged (0.01 to 0.03 mg/kg) due to lack of data and the potential risk of higher doses.

129. Potentially Reversible Causes of Arrest: 4 H’s
Hypoxemia
Hypovolemia
Hypothermia
Hyper-/hypokalemia and metabolic causes (eg, hypoglycemia)
Slide 36: Potentially Reversible Causes of Arrest: 4 H’s
Whenever the victim fails to respond to conventional therapy, search for and treat potentially reversible causes of arrest or failure to respond. These are the most common special resuscitation circumstances.
Specific rhythm evaluation may include alternative H’s and T’s (on next slide). For instance, if bradycardia is present, consider additional H’s, including the following:
Heart condition
Heart transplant
Heart block
Head injury (increased intracranial pressure)

130. Potentially Reversible Causes of Arrest: 4 T’s
Tamponade
Tension pneumothorax
Toxins/poisons/drugs
Thromboembolism (pulmonary)
Slide 37: Potentially Reversible Causes of Arrest: 4 T’s
Whenever the victim fails to respond to conventional therapy, you should search for and treat potentially reversible causes of arrest or failure to respond. These are common special resuscitation circumstances to consider.
Specific rhythm evaluation may include alternative T’s and H’s (see previous slide).
Additional T’s include coronary thrombosis.
Consider also other reversible causes of arrest or failure to improve, such as ACS (myocardial ischemia) associated with cocaine overdose or anomalous coronary artery.