Advanced Life Support Cardiopulmonary Emergency

Basic life support should continue uninterrupted until the arrival of appropriately trained personnel and equipment. Asystole is the primary rhythm encountered in pediatric practice, ventricular fibrillation accounting for less than 10% of cases. Pulseless electrical activity also presents as cardiac

arrest. The ambulance control center will notify the receiving Emergency Department in the event that resuscitation is in progress, to enable preparation of equipment and assembly of the designated arrest team. On arrival at the department, continue basic life support following reassessment of the airway, breathing and circulation, and simultaneously apply cardiac monitoring. Mucus, vomit or blood in the oropharynx can easily be suctioned and Magill’s forceps can be used to remove visible foreign bodies.

There are many condition which needed Advanced Life Support

1. Asystole and pulseless electrical activity
2. Ventricular fibrillation and pulseless ventricular tachycardi

Asystole and pulseless electrical activity

Asystole is the absence of a palpable pulse and of electrical activity (Figure 2.3), whereas pulseless electrical activity is failure to detect a pulse with the presence of electrical activity on the cardiac monitor. Pulseless electrical activity can deteriorate into asystole and together these account for the vast majority of cardiopulmonary arrests in childhood.

Treatment for both includes (Figure 2.5):

• 100% oxygen and ventilation, initially using bag and mask ventilation until definitive airway secured following intubation.

• Nasogastric tube insertion early on to decompress the stomach; if bag and mask ventilation continues, diaphragmatic splinting will occur and the risk of gastric aspiration is increased.

• Establish intravenous access (maximum of three attempts or 90 seconds), thereafter intraosseous access should be attempted if under 6 years of age.

• Epinephrine (adrenaline) administration at an initial dose of 0.1 ml kg−1 of 1/10000 (10micrograms kg−1). If this is ineffective, it should be repeated after 3 minutes of ongoing CPR. An increased dose of epinephrine (adrenaline) has not been shown to increase success and it can lead to myocardial damage.

• Epinephrine (adrenaline) can be inserted down the endotracheal route while vascular or intraosseous access is being established.

Ventricular fibrillation and pulseless ventricular tachycardia

Ventricular fibrillation (VF) (Figure 2.4) and pulseless ventricular tachycardia (pulseless VT) are rarely encountered in the childhood population, accounting for 10% of cardiac arrest rhythms. Pre-existing cardiac pathology, hypothermia following drowning and ingestion of tricyclic antidepressants all predispose to their development. The management of VF and pulseless VT follow the same algorithm (Figure 2.5).

If the arrest is witnessed, a precordial thump can be given in attempt to restart the heart. Prior to defibrillation gel pads should be applied to the apex and right sternal edge of the chest. If the child is under 10 kg, use pediatric paddles. If these are unavailable defibrillation can still be achieved by placing one paddle on the front and the other on the back of the chest.

Defibrillation with DC shock should proceed as in Figure 2.6.

If the arrhythmia persists, give 0.1 ml kg−1 1/10000 epinephrine (adrenaline) (10 µg kg−1) and follow with 1 minute of CPR before giving further three shocks of 4 J kg−1. If the VF and pulseless VT is still resistant, amiodarone at a dose of 5 mg kg−1 in a bolus is the treatment of choice followed by 4 J kg−1 DC shock 60 seconds after administration. CPR should continue with, stopping only