5. PEDIATRIC EMERGENCIES

5.5 PEDIATRIC CARDIOPULMONARY ARREST: ASYSTOLE / AGONAL IDIOVENTRICULAR RHYTHM / PULSELESS ELECTRICAL ACTIVITY (PEA)

Cardiopulmonary arrest in infants and children is usually the end result of deterioration in respiratory and circulatory function. Injury is the leading cause of death in children between 1 - 16 years. Other etiologies include, but are not limited to: severe dehydration, Sudden Infant Death Syndrome, congenital anomalies, airway obstruction, bacterial and viral infections, sepsis, asthma, hypothermia and drug overdose.

ASSESSMENT / TREATMENT PRIORITIES

1. Maintain universal blood and body fluid precautions.

2. Determine unresponsiveness, absence of breathing and pulselessness.

3. Maintain an open airway, remove secretions, vomitus, and initiate CPR with supplemental high concentration of oxygen.

4. Continually assess Level of Consciousness, ABCs and Vital Signs including capillary refill.

5. Obtain appropriate history related to event, including recent and Past Medical History, Medications, Drug Allergies and Substance Abuse including possible ingestion or overdose of medications. Observe for signs of child abuse (see appendix).

6. Symptomatic patients may have abnormally slow or rapid heart rates accompanied by decreased level of consciousness, weak and thready pulses, delayed capillary refill, or no palpable BLOOD PRESSURE.

7. Every effort should be made to determine the possible cause(s) for PEA including medical and/or traumatic etiologies.

TREATMENT

BASIC PROCEDURES

1. Maintain universal blood and body fluid precautions.

2. Determine unresponsiveness and cardiopulmonary arrest.

3. Maintain open airway and assist ventilations (ensure proper seal around the ventilation mask). This may include repositioning of the airway, suctioning to remove secretions and/or vomitus, or use of airway adjuncts as indicated. If indicated, treat spinal injury accordingly.

4. If unable to ventilate child after repositioning of airway: assume upper airway obstruction and follow Pediatric Upper Airway Obstruction Protocol.

5. Initiate Cardiopulmonary Resuscitation (CPR).

6. Activate ALS intercept, if deemed necessary and if available.

7. Initiate transport as soon as possible; with or without ALS. Keep child warm.

8. Notify receiving hospital

INTERMEDIATE PROCEDURES

1. Maintain universal blood and body fluid precautions.

2. Determine unresponsiveness and cardiopulmonary arrest.

3. Maintain open airway and assist ventilations (ensure proper seal around the ventilation mask). This may include repositioning of the airway, suctioning to remove secretions and/or vomitus, or use of airway adjuncts as indicated. If indicated, treat spinal injury accordingly.

4. If unable to ventilate child after repositioning of airway: assume upper airway obstruction and follow Pediatric Upper Airway Obstruction Protocol.

5. Initiate Cardiopulmonary Resuscitation (CPR).

6. ALS STANDING ORDERS

a. Provide Advanced airway management, if indicated.

b. Initiate IV Normal Saline KVO while enroute.

7. Contact MEDICAL CONTROL. Medical Control may order:

a. Normal Saline bolus at discretion of Medical Control (expected fluid bolus is 20 ml/kg)

8. Activate Paramedic intercept, if available.

9. Initiate transport with or without Paramedics.

10. Notify receiving hospital.

PARAMEDIC PROCEDURES

1. Maintain universal blood and body fluid precautions.

2. Determine unresponsiveness and cardiopulmonary arrest.

3. Maintain open airway and assist ventilations (ensure proper seal around the ventilation mask). This may include repositioning of the airway, suctioning to remove secretions and/or vomitus, or use of airway adjuncts as indicated. If indicated, treat spinal injury accordingly.

4. If unable to ventilate child after repositioning of airway: assume upper airway obstruction and follow Pediatric Upper Airway Obstruction Protocol.

5. Initiate Cardiopulmonary Resuscitation (CPR).

6. ALS STANDING ORDERS

a. Provide Advanced airway management, if indicated.

b. Initiate IV Normal Saline KVO. NOTE: If a vein can be visualized or palpated, establish an IV of Normal Saline KVO. If unable to visualize or palpate a vein and child is less than six years old, establish an intraosseous infusion of Normal Saline to keep the line open. If unable to visualize or palpate a vein and the child is greater than six years old, attempt external jugular access.

c. Epinephrine:

    • For Bradycardia: IV/IO: 0.01 mg/kg (1:10,000); ET: 0.1 mg/kg (1:1,000) followed by 2.0 cc of NS. Subsequent dosages: IV/IO repeat initial dose (0.01 mg/kg 1:10,000) every 3 - 5 minutes; subsequent ET dosages (0.1 - 0.2 mg/kg 1:1,000) every 3 - 5 minutes.
    • For Asystolic or PEA:

i. Initial Dose: IV/IO; 0.01 mg/kg (1:10,000); ET 0.1 mg/kg (1:1,000) followed by 2.0 cc of NS.

ii. Subsequent doses every 3 - 5 minutes: IV/IO/ET: 0.1 mg/kg (1:1,000) NOTE: Dosages as high as 0.2 mg/kg may be effective.

iii. Epinephrine infusion: initial dose 0.1 mg/kg/min. Titrate to desired effect to maximum dose of 1.0 mg/kg/min.

d. Atropine:

    • ET/IV/IO : 0.02 mg/kg (minimum dose 0.1 mg; maximum dose 0.5 mg in a child and 1.0 mg in an adolescent).

7. Contact MEDICAL CONTROL. Medical Control may order.

a. Fluid bolus(es) of Normal Saline (20 ml/kg).

b. Sodium Bicarbonate 1 mEq/kg: IV/IO

c. All other treatment modalities based upon suspected etiology for cardiopulmonary arrest.

8. Initiate Transport as soon as possible.

9. Notify receiving hospital.






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