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Issue 10 (1999) Article 7: Page 5 of 6   Go to page: 1 2 3 4 5 6
Paediatric Life Support (Continued)

Newborn Advanced Life Support (Figure 4)

Tracheal intubation is a skilled technique that requires training and practice. It is achieved, using a straight blade laryngoscope and an appropriate size of tracheal tube.

Guideline for tracheal tube size
Tracheal Tube Size
(mm. Internal Diameter)		Weight
(g)		Gestation
(weeks)
2.5<1000<28
31000 - 250028 - 36
3.5>2500>36

These are only guidelines and tubes 0.5mm larger and smaller should always be available.

 Figure4

Once the tracheal tube is passed through the vocal cords its position must be carefully checked to ensure that there is equal ventilation of both lungs. The tube should then be securely fixed in position. Ventilation is continued using the self-inflating bag or T-piece system.

WHEN THERE IS ANY DOUBT ABOUT THE POSITION OR PATENCY OF THE TUBE REMOVE THE TRACHEAL TUBE IMMEDIATELY AND REINTUBATE AFTER A BRIEF PERIOD OF OXYGENATION USING FACE MASK VENTILATION.

Circulation

The initial attempts at establishing a viable circulation are made using chest compressions. Chest compressions should be performed if:

  1. The heart rate is less than 60 beats/minute.
  2. The heart rate is less than 100 beats/minute and falls despite adequate ventilation.

The optimal technique is to place the 2 thumbs side by side over the lower one third of the sternum with the fingers encircling the torso and supporting the back.05-107 The lower third of the sternum45 is compressed 2 - 3cm in a term baby at a rate of approximately 120 compressions per minute. The compressions should be smooth and not jerky and each compression should last 50% of the compression/relaxation cycle. An alternative technique is to use the index and middle finger of one hand to compress the lower half of the infant's sternum. This allows the operator's free hand to perform simple resuscitation procedures whilst maintaining external chest compressions. A single ventilation should be performed after every three chest compressions. The pulse should be checked periodically and chest compressions only discontinued when the spontaneous heart rate of greater than 100 beats per minute is established.

If the infant fails to respond to active ventilation following intubation and chest compressions then venous access must be established. A failure of the infant to respond is usually as a result of inadequate ventilation and it is therefore essential to check the seal of the facemask or the position of the tracheal tube. When satisfied that there is optimal airway control and in the continuing absence of improvement, the umbilical vein should be catheterised using a 4.5 - 5 FG umbilical catheter. This is achieved by transecting the cord 1 - 2cm away from the abdominal skin and inserting the umbilical catheter until there is a free flow of blood up the catheter.

An initial dose of intravenous adrenaline, 10-30mcg.kg-1 (0.1 - 0.3 ml.kg-1 of 1:10,000 solution), should be given via the umbilical venous catheter, flushing the adrenaline through the catheter with 2ml of saline. If venous access fails, an intra-osseous needle can be inserted into the proximal tibia and this route temporarily used instead of the venous umbilical catheter. If there is a delay in establishing umbilical vein catheterisation or intraosseous access then the same dose of adrenaline, 10 - 30mcg.
kg-1, can be given through the tracheal tube. Despite the tracheal administration of adrenaline being widely practiced there is little evidence that it is effective.08-110 It may be least effective if given before the lungs are fully inflated.

If there is still no response the baby should be given 1 -2 mmol.kg-1 body weight of sodium bicarbonate slowly over 2-3 minutes. Use a 4.2% bicarbonate solution or mix a volume of 8.4% sodium bicarbonate solution with an equal volume of 5 or 10% dextrose or sterile water. This results in a concentration of 0.5mmol.ml-1 solution. Basic life support must be continued. Sodium bicarbonate is a hyperosmolar solution and should be administered by slow infusion in preterm babies below 32 weeks because of the risk of inducing intracerebral bleeding. Further doses of bicarbonate are best given in response to the results of arterial blood gas analysis data.

Repeat doses of adrenaline should be given if the newborn continues to fail to respond. Subsequent larger doses, up to 100mcg.kg-1, may be considered but there is evidence that the need for adrenaline during resuscitation is associated with a poor prognosis11.

Hypovolaemia in the newborn requires active volume replacement. Indications for intravenous fluid therapy are:

  1. Evidence of acute fetal blood loss.
  2. Pallor that persists after oxygenation.
  3. Faint pulses with a good heart rate and poor response to resuscitation including adequate ventilation.
  4. Fluid replacement, at 10-20mls.kg-1, can be given as 4.5% albumin, whole blood or plasma.

Finally, intramuscular naloxone (100mcg.kg-1) should be considered in the apnoeic newborn who rapidly becomes pink and who obviously has a satisfactory circulation on resuscitation. Naloxone is a narcotic antagonist and is specifically indicated where there is a history of recent therapeutic administration of opiates to the mother. [Top]

Conclusion

Paediatric life support is an essential part of the resuscitation cycle. To be effective, those practising paediatric resuscitation at basic or advanced levels need to be properly trained and practised in the skills of the procedure. Delay or hesitation in recognising the need for or performing resuscitation will have dire consequences. [Top]

Further Reading

  1. Hickey RW, Cohen DM, Strausbaugh S, Dietrich AM. Paediatric patients requiring CPR in the prehospital setting. Annals Emergency Medicine 1995;25:495-501.
  2. Innes PA, Summers CA, Boyd IM, Molyneaux EM. Audit of paediatric cardiopulmonary resuscitation. Archives Diseases Childhood 1993;68:487-491.
  3. Teach SJ, Moore PE, Fleisher GR. Death and resuscitation in the paediatric emergency department. Annals Emergency Medicine 1995;25:799-803.
  4. Thompson JE, Bonner B, Lower GM. Paediatric cardiopulmonary arrests in rural populations. Paediatrics 1990;86:302-306.
  5. Zaritsky A, Nadkarni V, Getson P, Kuehl K. CPR in children. Annals Emergency Medicine 1987; 16:1107-1111.
  6. Appleton GO, Cummins RO, Larson MP, Graves JR. CPR and the single rescuer: At what age should you 'call first' rather than 'call fast'? Annals Emergency Medicine 1995;25:492-494.
  7. Hazinski MF. Is Paediatric Resuscitation Unique? Relative merits of early CPR and ventilation versus early defibrillation for young victims of prehospital cardiac arrest. Annals Emergency Medicine 1995;25:540-543.
  8. Mogayzel C, Quan L, Graves JR, Tiedeman D, Fahrenbruch C, Herndon P. Out-of-Hospital Ventricular Fibrillation in children and Adolescents: Causes and Outcomes. Annals Emergency Medicine 1995; 25:484-491.
  9. Dieckmann RA, Vardis R. High-dose epinephrine in paediatric out-of-hospital cardiopulmonary arrest. Paediatrics 1995;95:901-913.
  10. Eisenberg M, Bergner L, Hallstrom A. Epidemiology of cardiac arrest and resuscitation in children. Annals Emergency Medicine 1983;12:672-674.
  11. Friesen RM, Duncan P, Tweed WA, Bristow G. Appraisal of paediatric cardiopulmonary resuscitation. Canadian Medical Association Journal 1982;126: 1055-1058.
  12. Losek J, Hennes H, Glaeser PW, Smith DS, Hendley G. Prehospital countershock treatment of paediatric asystole. American Journal Emergency Medicine 1989;7:571-575.
  13. O'Rourke PP. Outcome of children who are apneic and pulseless in the emergency room. Critical Care Medicine 1986;14:466-468.
  14. Ronco R, King W, Donley DK, Tilden SJ. Outcome and cost at a children's hospital following resuscitation for out-of-hospital cardiopulmonary arrest. Archives Pediatric Adolescent Medicine 1995;149:210-214.
  15. Schindler MB, Bohn D, Cox P, et al. Outcome of out-of-hospital cardiac or respiratory arrest in children. New England Journal Medicine 1996;335:1473-1479.
  16. Torphy DE, Minter MG, Thompson BM. Cardiorespiratory arrest and resuscitation of children. American Journal Diseases of Children 1984;138: 1099-1102.
  17. Lewis JK, Minter MG, Eshelman SJ, Witte MK. Outcome of pediatric resuscitation. Annals Emergency Medicine 1983;12:297-299.
  18. Otto CW, Yakaitis RW, Blitt CD. Mechanism of action of epinephrine in resuscitation from cardiac arrest. Critical Care Medicine 1981;9:321-324.
  19. Tunstall-Pedoe H, Bailey L, Chamberlain DA, Marsden AK, Ward ME, Zideman DA. Survey of 3765 cardiopulmonary resuscitations in British hospitals (the BRESUS Study): methods and overall results. British Medical Journal 1992;304:1347-1351.
  20. Zaritsky A, Nadkarni V, Hazinski MF, et al. Recommended guidelines for uniform reporting of paediatric advanced life support: the Paediatric Utstein Style. Resuscitation 1995;30:95-116.
  21. Advanced Life Support Committee of the Australian Resuscitation Council. Paediatric advanced life support: the Australian Resuscitation Council guidelines. Medical Journal Australia 1996;165:199-206.
  22. Emergency Cardiac Care Committee and Subcommittees of the American Heart Association. Guidelines for cardiopulmonary resuscitation and emergency cardiac care. Journal American Medical Association 1992;268:2171-2302.
  23. Kloeck WGJ. Resuscitation Council of Southern Africa Guidelines: New Recommendations for basic life support in adults, children and infants; Obstructed airway in adults, children and infants; Advanced life support for adults and children. Trauma and Emergency Medicine 1993;10(1):738-771.
  24. European Resuscitation Council.Guidelines for paediatric life support. Resuscitation 1994;27:91-106.
  25. Nadkarni V, Hazinski MF, Zideman DA, et al. Paediatric Life Support: An advisory statement by the Paediatric Life Support Working Group of the International Liaison Committee on Resuscitation. Resuscitation 1997; 34:115-127.
  26. European Resuscitation Council. Paediatric Basic Life Support. Resuscitation 1998;37:97-100.
  27. European Resuscitation Council. Paediatric Advanced Life Support. Resuscitation 1998;37:101-102.
  28. European Resuscitation Council. Recommendations on Resuscitation of Babies at Birth. Resuscitation 1998;37:103-110.
  29. European Resuscitation Council. Guidelines for basic life support . Resuscitation 1992;24:103-110.
  30. European Resuscitation Council. Guidelines for advanced life support . Resuscitation 1992;24:111-121.
  31. Ruben HM, Elam JO, Ruben AM, Greene DG. Investigation of upper airway problems in resuscitation, I: studies of pharyngeal x-rays and performance by laymen. Anesthesiology 1961;22:271-279.
  32. Wheeler M, Roth A, Dunham M, Rae B, Cote C. A bronchoscopic, computer-assisted examination of the changes in dimension of the infant tracheal lumen with changes in head position. Anaesthesiology 1998;88:1183-1187.
  33. Baskett PJF, Nolan JP, Parr MJ. Tidal volumes perceived to be adequate for resuscitation. Resuscitation 1996.
  34. Segedin E, Torrie J, Anderson B. Nasal airway versus oral route for infant resuscitation. Lancet 1995;346:382.
  35. Tonkin SL, Davis SL, Gunn TR. Nasal route for infant resuscitation by mothers. Lancet 1995;345:1353-1354.
  36. Melker RJ. Asynchronous and other alternative methods of ventilation during CPR. Annals Emergency Medicine 1984;13(2):758-761.
  37. Melker RJ, Banner MJ. Ventilation during CPR: two- rescuer standards reappraised. Annals Emergency Medicine 1985;14:397-402.
  38. Bowman F, Menegazzi J, Check B, Duckett T. Lower oesophageal sphincter pressure during prolonged cardiac arrest and resuscitation. Annals Emergency Medicine 1995;26:216-219.
  39. Cavallaro DL, Melker RJ. Comparison of two techniques for detecting cardiac activity in infants. Critical Care Medicine 1983;11:198-200.
  40. Brearley S, Simms MH, Shearman CP. Peripheral pulse palpation: An unreliable sign. Annals of Royal College of Surgeons of England 1992;74:169-172.
  41. Mather C, O'Kelly S. The palpation of pulses. Anaesthesia 1996;51:189-191.
  42. Monsieurs KG, De Cauwer HG, Bossaert LL. Feeling for the carotid pulse: is five seconds enough? Resuscitation 1996;31:S3.
  43. Monsieurs KG, De Cauwer HG, Bossaert LL. Obesity of the victim negatively influences carotid pulse checking performance. Resuscitation 1996;31:S6.
  44. Connick M, Berg RA. Femoral venous pulsations during open-heart cardiac massage. Annals Emergency Medicine 1994;24(6):1176-1179.
  45. Phillips G, Zideman DA. Relation of infant heart to sternum: its significance in cardiopulmonary resuscitation. Lancet 1986;i:1024-1025.
  46. Kuisma M, Suominen P, Korpela R. Paediatric out-of- hospitalcardiac arrests - epidemiology and outcome. Resuscitation 1995;30:141-150.
  47. Gillis J, Dickson D, Rieder M, Steward D, Edmonds J. Results of inpatient paediatric resuscitation. Critical Care Medicine 1986;14:469-471.
  48. Walsh CK, Krongrad E. Terminal cardiac electrical activity in paediatric patients. American Journal Cardiology 1983;51:557-561.
  49. Alexander R, Hodgson P, Lomax D, Bullen C. A comparison of the laryngeal mask airway and guedel airway, bag and facemask for manual ventilation. Anaesthesia 1993;48:231-234.
  50. Davies PRF, Tighe SQM, Greenslade GL, Evans GH. Laryngeal mask airway and tracheal tube insertion by unskilled personnel. Lancet 1990;336:977-979.
  51. De Mello WF, Ward P. The use of the laryngeal mask airway in primary anaethesia. Anaesthesia 1990; 45:793-794.
  52. Martin PD, Cyna AM, Hunter WA, Henry J, Ramayya GP. Training nursing staff in airway management for resuscitation. Anaesthesia 1993;48:133-137.
  53. Pennant JH, Walker M. Comparison of the endotracheal tube and the laryngeal mask in airway management by paramedical personnel. Anesthesia and Analgesia 1992;74:531-534.
  54. Samarkandi AH, Seraj MA, El Dawlathy A, Mastan M, Bahamces HB. The role of the laryngeal mask airway in cardiopulmonary resuscitation. Resuscitation 1994;28:103-106.
  55. Brunette DD, Fischer R. Intravascular access in pediatric cardiac arrest. American Journal Emergency Medicine 1988;6:577-579.
  56. Kanter RK, Zimmerman JJ, Strauss RH. Pediatric emergency intravenous access: evaluation of a protocol. American Journal Disease Children 1986;140:132-134.
  57. Dalsey WC, Barsan WG, Joyce SM. Comparison of superior vena caval access using a radioisotope technique during normal perfusion and cardiopulmonary resuscitation. American Journal Emergency Medicine 1984;13:881-884.
  1. Emerman CL, Pinchak AC, Hancock D, Hagen JF. Effect of injection site on circulation times during cardiac arrest. Critical Care Medicine 1988;16(11):1138-1141.
  2. Rosa DM, Griffen CC, Flanagan JJ, Machiedo GW. A comparison of intravenous access sites for bolus injections during shock and resuscitation after emergency room thoracotomy with and without aortic crossclamping. Annals Surgery 1990;56:566-570.
  3. Barsan WG, Levy RC, Weir H. Lidocaine levels during CPR: differences after peripheral venous, central venous, and intracardiac injections. Annals Emergency Medicine 1981;10:73-78.
  4. Hedges JR, Barsan WB, Doan LA. Central versus peripheral intravenous routes in cardiopulmonary resuscitation. American Journal Emergency Medicine 1981;10:417-419.
  5. Kuhn GJ, White BC, Swetman RE. Peripheral versus central circulation time during CPR: a pilot study. Annals Emergency Medicine 1981;10:417-419.
  6. Emerman CL, Pinchak AC, Hancock D, Hagen JF. The effect of bolus injection on circulation times during cardiac arrest. American Journal Emergency Medicine 1990;8:190-193.
  7. Andropoulos D, Soifer S, Schreiber M. Plasma epinephrine concentrations after intraosseous and central venous injection during cardiopulmonary resuscitation in the lamb. Journal Pediatrics 1990;116(2):312-315.
  8. Orlowski JP, Porembka DT, Gallagher JM, Lockren JD, Van Lente F. Comparison study of intaosseous, central intravenous and peripheral intarvenous infusions of emergency drugs. American Journal Diseases Children 1990;144:112-117.
  9. Rosetti VA, Thompson BM, Miller J, Mateer JR, Aprahamian C. Intraosseous infusion: an alternative route of paediatric intravascular access. Annals Emergency Medicine 1995;14:885-888.
  10. Valdes MM. Intraosseous fluid administration in emergencies. Lancet 1977;1:1235-1236.
  11. Glaeser PW, Hellmich TR, Szewczuga D, Losek JD, Smith DS. Five-year experience in prehospital intraosseous infusions in children and adults. Annals Emergency Medicine 1993;22:1119-1124.
  12. Fiser D. Intraosseous infusion. New England Journal Medicine 1990;322:1579-1581.
  13. Spivey WH. Intraosseous infusions. Journal Pediatrics 1987;111:639-643.
  14. Ummenhofer W, Frei F, Urwyler A, Drewe J. Emergency laboratory studies in paediatric patients (abstract). Resuscitation 1992;24:185.
  15. LaFleche FR, Slepin MJ, Vargas J, Miltzman DP. Iatrogenic bilateral tibial fractures after intraosseous infusion attempts in a 3-month-old infant. Annals Emergency Medicine 1989;18:1099-1101.
  16. Christensen DW, Vernon DD, Banner WJ, Dean JM. Skin necrosis complicating intraosseous infusion. Pediatric Emergency Care 1991;7:289-290.
  17. Simmons CM, Johnson NE, Perkin RM, Van Stralen D. Intraosseous extravasation complication reports. Annals Emergency Medicine 1994;23:363-366.
  18. Galpin RD, Kronick JB, Willis RB, Frewen TC. Bilateral lower extremity compartment syndromes secondary to intraosseous fluid resuscitation. Journal Pediatric Orthopedics 1991;11:773-776.
  19. Moscati M, Moore GP. Compartment syndrome with resultant amputation following intraosseous infusion. American Journal Emergency Medicine 1990;8:470-471.
  20. Rimar S, Westry J, Rodriguez R. Compartment syndrome in an infant following emergency intraosseous infusion. Clinics Pediatrics 1988;27:259-260.
  21. Greenberg MI, Roberts JR, Baskin SI. Use of endotracheally administered epinephrine in a pediatric patient. American Journal Diseases Children 1981;135:767-768.
  22. Lindemann R. Tracheal administration of epinephrine during cardiopulmonary resuscitation. American Journal Diseases Childhood 1982;136:753.
  23. Jasani M, Nadkarni V, Finkelstein M, Mandell G, Salzman S, Norman M. Critical Care Medicine. 1994;22:1174-1180.
  24. Mazkereth R, Paret G, Ezra D, et al. Epinephrine blood concentrations after peripheral bronchial versus endotracheal administration of epinephrine in dogs. Critical Care Medicine 1992;20:1582-1587.
  25. Quinton D, O'Byrne G, Aitkenhead A. Comparison of endotracheal and peripheral venous intravenous adrenaline in cardiac arrest: is the endotracheal route reliable. Lancet 1987;1:828-829.
  26. Roberts J, Greenberg M, Knaub, Kendrick Z, Baskin S. Comparison of the pharmacological effects of epinephrine administered by the intravenous and endotracheal routes. Journal American College Emergency Physicians 1978;7:260-264.
  27. Hahnel JH, Lindner KH, Ahnefeld KFW. Endobronchial administration of emergency drugs. Resuscitation 1989;7:261-272.
  28. Hornchen U, Schuttler J, Stoekel H. Influence of the pulmonary circulation on adrenaline pharmacokinetics during cardiopulmonary resuscitation. European Journal Anaesthesiology 1992;9:85-91.
  29. Hornchen U, Schuttler J, Stoeckel H, Eichelkraut W, Hahn N. Endobronchial instillation of epinephrine during cardiopulmonary resuscitation. Critical Care Medicine 1987;15:1037-1039.
  30. Orlowski JP, Gallagher JM, Porembka DT. Endotracheal epinephrine is unreliable. Resuscitation 1990;19:103-113.
  31. Ralston SH, Tacker WA, Showen L, Carter A, Babbs CF. Endotracheal versus intravenous epinephrine during electromechanical dissociation with CPR in dogs. Annals Emergency Medicine 1985;14:1044-1048.
  32. Bleyaert AL, Sands PA, Safar P, et al. Augmentation of postischemic brain damage by severe intermittent hypertension. Critical Care Medicine 1980;8:41-45.
  33. Kosnik JW, Jackson RE, Keats S, Tworek RM, Freeman SB. Dose-related response of centrally administered epinephrine on the change in aortic diastolic pressure during closed chest massage in dogs. Annals Emergency Medicine 1985;14:204-208.
  34. Patterson M, Boenning D, Klein B. High dose epinephrine in paediatric cardiopulmonary arrest. Paediatric Emergency Care. 1994;10:310.
  35. Fiser DH, Wrape V. Outcome of cardiopulmonary resuscitation in children. Pediatric Emergency Care 1987;3:235-237.
  36. Nichols DG, Kettrick RG, Swedlow DB, Lee S, Passman R, Ludwig S. Factors influencing outcome of cardiopulmonary resuscitation in children. Paediatric Emergency Care 1986;2:1-5.
  37. World Health Organisation. World Health Report. 1995;21.
  38. Apgar V, James LS. Further observations of the newborn scoring system. American Journal of Diseases of Children 1962;104:419-428.
  39. Chamberlain G, Banks J. Assessment of the Apgar Score. Lancet 1974;ii:1225-1228.
  40. Codero L, How EH. Neonatal bradycardia following nasopharyngeal suction. Journal Pediatrics 1971;78:441.
  41. Palme C, Nystrom B, Tunell R. An evaluation of the efficiency of face masks in the resuscitation of the newborn infants. Lancet 1985;i:207-210.
  42. Hoskyns EW, Miner AD, Hopkin IE. A simple method of face mask resuscitation at birth. Archives Diseases of Childhood 1987;62:376-379.
  43. Lundstrom KE, Pryds O, Greisen G. Oxygen at birth and prolonged cerebral vasoconstriction in preterm infants. Archives Diseases Childhood 1995;73:F81-F86.
  44. Svenningsen NW, Stjernquist K, Stavenow S, Hellstrom- Vestas L. Neonatal outcome of extremely low birth weight liveborn infants below 901g in a Swedish population. Acta Paed Scand 1989;78:180-188.
  45. Ballot DE, Rothberg AD, Davies VA, Smith J, Kirsten G. Does hypoxemia prevent brain damage in birth asphyxia? Medical Hypotheses 1993;41(Suppl 4):
  46. Ramji S, Ahuja S, Thirupuram S, Rootwelt T, Rooth G, Saugstad OD. Resuscitation of asphyxic newborn infants with room air or 100%oxygen. Pediatric Research 1993;34(Suppl 6):809-812.
  47. Vyas H, Milner AD, Hopkin IE, Boon AW. Physiologic responses to prolonged slow rise inflation in the resuscitation of the asphyxiated newborn infant. Journal Pediatrics 1981;99:635-639.
  48. Thaler MM, Stobie GHC. An improved technique of external cardiac compression in infants and young children. New England Journal Medicine 1963;269 606-610.
  49. Todres ID, Rogers MC. Methods of external cardiac massage in the newborn infant. Journal Pediatrics 1975;86:781-782.
  50. David R. Closed chest cardiac massage in the newborn infant. Pediatrics 1988;81:552-554.
  51. Lindemann R. Resuscitation of the new-born: endotracheal administration of epinephrine. Acta Paediatric Scand 1984;73:210-212.
  52. Lucas VW, Preziosi MP, Burchfield DJ. Epinephrine absorption following endotracheal administration: effects of hypoxia-induced low pulmonary blood flow. Resuscitation 1997;27:31-34.
  53. Mullett CJ, Kong JQ, Romano JT, Polak MJ. Age related changes in pulmonary venous epinephrine concentration and pulmonary vascular response after intratracheal epinephrine. Paediatric Research 1992;31:458-461.
  54. Sims DG, Heal CA, Bartle SM. The use of adrenaline and atropine in neonatal resuscitation. Archives Diseases Childhood 1994;70:F3-F10. [Top]


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