Elegard - Pediatric

Procedure Guidelines

Elegard - Pediatric

Therapeutic Goal To recognize the pediatric patient requiring cardiopulmonary resuscitation and to restore a stable cardiac rhythm with adequate cardiac output and perfusion leading to neurologically intact survival.

Assessment / Pathophysiology

• Most cardiac arrest in infants and children is secondary to other causes (respiratory insult, illness, congenital heart defect, drowning, etc.) rather than coronary artery disease. Respiratory problems are common in infants and children, and can quickly progress to respiratory failure, then cardiopulmonary arrest. Dysrhythmias are rare, except as an agonal event.
• Treatment should aim to achieve ROSC with good neurological outcome. Efforts should be directed at high quality and continuous compressions with limited interruptions and early defibrillation when indicated. Beginning compressions first is recommended in pediatric patients during CPR. Compressions should be coupled with ventilations, early attention to airway management and oxygenation. Patient survival is often dependent on proper airway management.
• Consider early IO placement if available and/or difficult IV access anticipated. Consider the secondary causes that lead to hypoventilation/apnea and treat accordingly.
• Success is based on proper planning and execution. Procedures require space and patient access. Make room to work.

This policy is for medical cardiac arrest and does not apply to hemorrhagic traumatic arrest. For the pediatric patient EleGARD use is appropriate for anyone who is of adult size based on the pediatric protocol criteria for cardiac arrest; 7.01 PEDIATRIC ASYSTOLE, 7.02 PEDIATRIC PULSELESS ELECTRICAL ACTIVITY (PEA), 7.03 PEDIATRIC VENTRICULAR FIBRILLATION /PULSELESS VENTRICULAR TACHYCARDIA

General Care

   •	Ensure the patient is pulseless and that resuscitation is indicated. If there is doubt whether 
            or not to start a resuscitation, start the process.
   •	Perform a rapid scene survey for any evidence of a valid DNR order and or directive.
   •	Apply cardiac monitor and reassess rhythm and pulse every 2 minutes.
   •	Utilize time in-between procedures to optimize care and trouble shoot any H’s and T’s.
   •	Ensure high quality compressions are performed continuously throughout the code.
   •	Compressions should be delivered at a rate of 100-120 compression per minute.
   •	Compress ≥ 1/3 anterior-posterior diameter of chest (infants 1.5”, children 2”).
   •	If two rescuers are on scene utilize the 15 compressions to 2 ventilations ratio until an 
           advanced airway is established. Single rescuers should use the 30 compressions to 2 
           ventilations ratio until additional personnel arrives on scene. Provide adequate   
           appropriately timed ventilations
   •	Airway is a more important intervention in pediatric arrests. This should be accomplished 
           quickly with a BVM with OPA/NPA or Supraglottic airway.
   •	It is preferred to place a supraglottic airway as the first line attempt when placing an  
          advanced airway.

Cardiac Arrest (Ped)

   •	Do not hyperventilate: Once an advanced airway is placed, ventilate 8-10 
           bpm (i.e. 1 breath: 6 seconds) with continuous, uninterrupted compressions.
   •	Attach ETCO2 filter line once advanced airway is placed. ETCO2 goal in cardiac 
           arrest is >10mmHg.
   •	Continually reassess for proper airway placement. Targeted treatment and
           appropriately timed medications.
   •	Initiate IV/IO for medication administration. Humeral IO placement is preferred in 
           older children as the initial access point. In younger children tibial IO placement is   
           preferred.
   •	Recording the time that a medication is given is of paramount importance, so that 
           medications are being given at the appropriate interval. The team leader should be  
           responsible for this task, unless delegated to another team member.
   •	Reassess rhythm and pulse every 2 min.

VFIB / VTACH:

              Defibrillate at 2 J/KG as soon as possible.

• If AED is already in place, defibrillate as indicated. Otherwise, place patient on the monitor/defibrillator as soon as practical. • Continue to defibrillate at 2 min intervals in a step wise fashion: 4 J/KG, 10 J/KG, until ROSC or the rhythm changes to a non-shockable rhythm. • Compressions should be continued while the defibrillator is charging and should resume immediately following any defibrillation. Medication Administration: Administer as indicated. • EPINEPHRINE 0.01 MG/KG (0.1 ML/KG) 1:10,000 IV/IO. Repeat every 3-5 min • AMIODARONE 5 MG/KG IV/IO (Max: 300 MG), repeat once in 3-5 min (Max repeat dose 150MG). • MAGNESIUM SULFATE 50 MG/KG IV/IO (Max: 2G) for: Polymorphic VT, suspected hypomagnesemia, or refractory VF/VT. • SODIUM BICARB 1 MEQ/KG IV/IO for: known pre-existing bicarbonate responsive acidosis, Tricyclic antidepressant (TCA) overdose, barbiturate overdose, or after a prolonged resuscitation. Bicarb can be repeated in 20 mins if cardiac arrest persists.

ASYSTOLE / PEA: • Administer EPINEPHRINE 0.01 MG/KG (0.1 ML/KG) 1:10,000 IV/IO. Repeat every 5 minutes for continued Asystole/PEA. • Consider SODIUM BICARB 1 MEQ/KG IV/IO for conditions listed above. • Consider CALCIUM CHLORIDE 20 MG/KG slow IV/IO (Max: 1G) for suspected hyperkalemia (e.g. dialysis patients).

The optimal airway technique for cardiac arrest is unknown and is likely to depend on the skills of the operator, the anticipated prehospital time and patient-dependent factors, therefore it is acceptable to place a supraglottic airway as the first go to airway if deemed difficult. This is preferred over multiple time-consuming attempts at intubation while delaying compressions.