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So now we're gonna talk about one of the probably the most anxiety-driving situations a healthcare professional can get into. And that's pulseless arrest cases with pediatrics. In this case we're gonna be talking about ventricular fibrillation. Now trauma or severe injury is one of the leading causes of out-of-hospital cardiac arrest in children. Even so, the treatment for a pediatric trauma victim in cardiac arrest is the same as a child in non-traumatic cardiac arrest. We're gonna support circulation, airway, and breathing. This, with the exception that in the case where the arrest is due to a mechanical form of shock, and treatment can be performed immediately to relieve the cause of the obstructive shock, we're still gonna follow the same algorithm. Ventricular fibrillation, known as V-Fib, and pulse ventricular tachycardia, known as V-Tach, are lethal dysrhythmias that do not produce a pulse. V-Fib is the most common initial dysrhythmia in cardiac arrests, and will regress to asystole if it's not treated right away. The key steps to treating V-Fib are rapid assessment to confirm cardiac arrest, starting CPR, and applying the defibrillator and delivering the first shock as soon as possible. Getting to the first shock early on is important, as statistically every minute that defibrillation is delayed, the chance of survival is reduced by about 10%. Now for a child or infant, high quality CPR needs to be performed with as few interruptions as possible by giving cycles of 15 compressions at least 1/3 the depth of the chest at a rate of 100 to 120 compressions per minute. This followed by two full rescue breaths to get chest rise and fall. This is gonna be about two inches deep on a child or one and a half inches deep for an infant when it comes to compression depth. The compressor needs to be changed every two minutes to avoid fatigue, which could lead to less effective CPR compressions. So after the initial defibrillation shock, an IV or IO needs to be established in order to be able to give medications. The first medication given would be epinephrine one to 10,000 and that's gonna be given 0.01 milligrams per kilogram IV or IO push every three to five minutes. Keep in mind that a 20 cc bolus of normal saline should be pushed after that so that we get the medication into the circulatory system of the patient. After the initial dose of epinephrine and a second shock is given, consider placing an advanced airway with capnography. Remember that once an advanced airway is in place, CPR compressions become continuous at 100 to 120 compressions per minute, and one breath is given every six seconds synchronized with those compressions. And if the patient remains in persistent V-Fib after the initial shocks and epinephrine administration, the next medication to be given is amiodarone, five milligrams per kilogram via rapid IV or IO push. Two more does of amiodarone may be repeated. Successful treatment of V-Fib continues with high quality CPR. Reassessing the patient's cardiac rhythm every two minutes, delivering a shock if V-Fib is present, and giving medications as indicated. Now another side note is that any pulseless arrest such as V-Fib, V-Tach, or PEA, or even asystole for that matter, needs to include nearly continuous CPR. The only thing that should cause an interruption is brief rhythm checks. Remember, we don't want to interrupt CPR to administer drugs. IO and IV drugs need to be given while those chest compressions are actually being done, in order to get the drug circulated to the heart and throughout the body, and also keep good circulation to vital organs and tissues. Aggressive and non-interrupted CPR is showing great improvements to patient outcomes and more importantly improved post-resuscitation quality of life.
In this lesson, we'll cover pulseless arrest, including the two types of pulseless arrest, and how to treat for the most common type – ventricular fibrillation, or VFib.
Pulseless arrest is one of the more anxious situations for most healthcare providers, particularly when it involves pediatric patients. VFib and ventricular tachycardia, or V-tach, are both lethal dysrhythmias that do not produce a pulse.
Trauma, or severe injuries, are one of the leading causes of out-of-hospital cardiac arrest in children. Even so, the treatment for pediatric trauma victims in cardiac arrest is the same as it is for children in non-traumatic cardiac arrest. Which is to support the patient's ABCs:
Pro Tip #1: In pediatric cases where the arrest is due to a mechanical form of shock and in which treatment can be performed immediately to relieve the cause of the obstructive shock, you should still follow the same algorithm.
VFib is the most common initial dysrhythmia in cardiac arrest patients and will regress further to asystole if it isn't immediately treated.
The key steps to treating VFib are as follows:
Pro Tip #2: Delivering a first shock as soon as possible is extremely important, as statistically, every minute that defibrillation is delayed, the chance of survival is reduced by about 10 percent.
As a healthcare professional, providing high quality CPR is always a priority. But for a child or infant, high quality CPR needs to be performed with as few interruptions as possible.
This means a number of things, but it starts with giving cycles of 15 chest compressions at a depth of 1/3 the depth of the chest and at a rate of 100 to 120 compressions per minute.
This should be followed by 2 rescue breaths, and make sure it's enough to get the patient's chest to rise and fall.
Chest compression depth will vary based on the patient's size, so these are merely averages:
Child chest compressions – about 2 inches in depth.Infant chest compressions – about 1.5 inches in depth.
Pro Tip #3: To ensure the quality of CPR being performed remains high, change the compressor every 2 minutes – or sooner if needed – to avoid fatigue, which often leads to less than optimal CPR compressions.
After the initial defibrillation shock has been delivered, an IV or IO needs to be established in order to administer medications.
The first medication given is epinephrine, and this should be administered using the 1:10,000 concentration at .01mg/kg via either IV or IO push every 3 to 5 minutes. And remember that a 20cc bolus of normal saline should be pushed after that to get the medication into the patient's circulatory system.
After the initial dose of epinephrine has been delivered, and after a second shock is given, consider placing an advanced airway with capnography. Also, once the advanced airway is in place, continue to perform high quality chest compressions at a rate of 100 to 120 per minute. And 1 rescue breath is given every 6 seconds synchronized with those compressions.
If the patient remains in persistent VFib after the initial shocks and epinephrine administration, the next medication to be given is amiodarone at 5mg/kg via rapid IV or IO push. Two more doses of amiodarone may be repeated.
The successful treatment of VFib continues with:
Pro Tip #4: Any pulseless arrest, such as VFib, V-tach, or even PEA and asystole, needs to include nearly continuous high-quality CPR. The ONLY thing that should interrupt CPR are brief rhythm checks.
Also important to note – you do not want to interrupt CPR to administer drugs. IV or IO administration of medications should be given while chest compressions are being performed in order to get the drugs circulated to the patient's heart and throughout their body, and to keep good circulation to their vital organs and tissues.
Aggressive and non-interrupted CPR has shown great improvement to pediatric patient outcomes, and more importantly, their improved post-resuscitation quality of life.