CARDIOPULMONARY RESUSCITATION (CPR)

Starship Children’s Health Clinical Guideline Note: The electronic version of this guideline is the version currently in use. Any printed version can not be assumed to be current. Please remember to read our disclaimer.

CARDIOPULMONARY RESUSCITATION (CPR)         

Alert the Emergency Team Algorithm ABC – Assess & Manage Defibrillation Medications Disability Exposure Secondary Survey Emergency Team Roles – Medical

 Emergency Team Roles - Nursing Role in

Wards  Post-Resuscitation Management

 Ceasing Resuscitation Efforts Parents & Family  Documentation Requirements for Deceased Patients  References  Appendix 1 - AEDs  Appendix 2 – Intraosseus Insertion

Alert the Emergency Team. Dial 777 Specify PAEDIATRIC CODE BLUE (i.e. Paediatric Arrest) Tell the operator the following information H Hospital e.g. Starship and whether adult or paediatric patient E Extension you are calling from L Location e.g. 24B room 6 P Problem e.g. paediatric code blue

Drug Calculator: A calculator for Paediatric resuscitation Drug doses can be found on the ADHB Intranet at L:Groups\EVERYONE\Starship\Paed Resus Form N.B. These guidelines apply to the resuscitation of infants (beyond the newborn period) and children (until puberty) For neonatal resuscitation please refer to http://www.adhb.govt.nz/newborn/teachingresources/resuscitation/resuscitation.htm For adult resuscitation please refer to Adult CPR guideline

Disclaimers: This guideline is intended for health professional use in the hospital resuscitation setting. Lay rescuers should refer to the NZRC guideline: http://www.nzrc.org.nz/assets/Uploads/arcbasiclifesupport.pdf

Author: Editor:

D Dr M Shepherd & Dr D Rasanathan Dr G Nuthall

Cardiopulmonary Resuscitation (CPR)

Service: CED, Paeds Resuscitation Committee Date Reviewed: August 2011 Page:

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CARDIOPULMONARY RESUSCITATION (CPR) Algorithm

Author: Editor:

D Dr M Shepherd & Dr D Rasanathan Dr G Nuthall, Dr R Gavin

Cardio-pulmonary Resuscitation


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CARDIOPULMONARY RESUSCITATION (CPR) ABC - Assess and Manage Ideally the assessment and management of Airway, Breathing and Circulation should occur simultaneously

Airway 

Position head to open obstructed airway (“neutral” position, not excessively extended or flexed)

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Immobilise cervical spine if trauma

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Jaw thrust or chin lift if still obstructed

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Suction under direct vision if necessary

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Place a Guedel airway if appropriate

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Intubate if necessary

(Note that intubation should only be performed by proficient personnel and should not delay other resuscitation efforts. It will usually be performed after basic life support has been initiated.) 

Endotracheal Tube size – estimated by [(Age(years)/ 4 )+4] - uncuffed [(Age(years)/ 4 )+3.5] - cuffed

Breathing 

If absent or ineffective, start ventilation with a blob mask or bag mask ventilation if competent

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2 initial breaths

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If patient has adequate respiratory effort place in high flow (>10 L/minute) oxygen via mask

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During active resuscitation the highest available concentration of oxygen should be given

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End Tidal CO2 – continuous End Tidal CO2 monitoring should be used wherever possible

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No End Tidal CO2 with chest compressions – suggests lack of ventilation – check airway (Endotracheal Tube) and ventilation

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Low End Tidal CO2 – suggests inadequate chest compressions, excessive ventilation or a reversible cause like pneumothorax or hypovolaemia or tamponade

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High End Tidal CO2 – suggests inadequate ventilation

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Return of spontaneous circulation may be identified by rapid rise in end tidal CO2

Author: Editor:




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CARDIOPULMONARY RESUSCITATION (CPR)

Circulation

PUSH HARD, PUSH FAST, DON’T STOP Compression Rate

100/minute 

     

Compression/Respiration ratio

15:2

Check for signs of circulation o Unresponsive, absent or ineffective breathing o This may include feeling for a brachial or femoral pulse, if absent or inadequate (e.g. less than 60/minute) commence external cardiac compressions o If there is any doubt regarding the presence of adequate circulation, then chest compressions must be started The lower sternum should be compressed by at least 1/3 of the AP diameter, >5cm (>4cm in infants). DO NOT INTERRUPT compressions Pauses should be brief (ideally 8 years  AEDs may be used  Paediatric energy adjustment is not required Children ≤ 8 years  Manual defibrillator is preferred  AEDs may be used  Ideally with “teddy bear” paediatric pads for the FR2 AED (which reduce energy delivered to 50J).  If these are not available then defibrillate without energy adjustment

Appendix 2 - Intraosseous Insertion Intraosseous (IO) infusions are a safe and reliable means of delivering drugs and fluids in patients when intravenous access is unavailable. Drugs should be flushed with 10mls of normal saline. IO fluids require pressure assisted flow as gravity flow is generally slow. Relative contraindications include osteoporosis, osteogenesis imperfecta, fractured bone, recent use of the same bone for IO infusion, or insertion through areas of cellulitis, infection, or burns. In most resuscitations at Starship if intraosseous access is required the EZ-IO drill is used. 1) Identify the infusion site. The landmarks for the upper tibial and lower femoral sites are shown below. TIBIAL

Anterior surface, 2 - 3 cm below the tibial tuberosity

FEMORAL

Anterolateral surface, 3 cm above the lateral condyle

2) Clean the skin over the chosen site 3) EZ-IO drill a) Attach appropriate length needle to drill b) Insert needle at 90o to the skin (at least 5mm of needle must be free from skin upon contact with cortex c) Drill through cortex 4) Cook IO needle a) Grasp needle with fingers and thumb near tip of needle and flat plastic portion resting in palm b) Insert the needle at 90o to the skin c) Continued to advance the needle with a twisting motion until a give is felt as the cortex is penetrated 5) Attach the 5 ml syringe and aspirate or infuse to confirm correct positioning 6) Attach the filled 50 ml syringe and push in the infusion fluid in boluses Author: Editor:




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CARDIOPULMONARY RESUSCITATION (CPR) 7) Possible Complications  Extravasation of fluid - especially in fractured bone or after previous IO attempts in same bone  Infection - osteomyelitis, cellulitis  Epiphyseal injuries - decrease risk by observing landmarks and keeping needle perpendicular to bone  Fat embolism - theoretical complication only

Author: Editor:




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