CAPÍTULO I. DEFINICIÓN DEL PROBLEMA
1.6. Antecedentes
1.6.4. Razones para la utilización de revestidores
Note:
• These guidelines are based on the principals of Cardiocerebral Resuscitation (CCR) and endorse the AHA 2005 Guidelines movement towards uninterrupted, quality chest compressions. They go further to reduce the biggest two obstacles of a successful resuscitation: interrupted chest
compressions and positive pressure ventilation.
• Unlike adult cardiac arrest, which is usually due to a primary cardiac abnormality, pediatric cardiac arrest most often occurs as a result of asphyxia. The most common reasons for this include progressive respiratory failure and shock.
Priorities Assessment Findings
Chief Complaint Collapsed, unresponsive, not breathing normally
OPQRST Witnessed or unwitnessed? Estimated time of onset. Circumstances/trauma.
Location of patient. Antecedent symptoms/signs (chest pain, difficulty breathing). Environmental factors, medication-related problems or overdose.
Associated Symptoms/
Pertinent Negatives
Bystander-initiated CPR. Pre-arrival CPR instructions from dispatch? Public access AED use.
SAMPLE Does the patient have any allergies to medications? History of heart disease?
Current cardiac medications?
Initial Exam Open airway, check for normal breathing, if none, begin chest compressions.
Detailed Focused Exam Vitals Signs: non-breathing (or agonal respirations/gasps)
General: Look for rigor mortis, dependent lividity, or unsurvivable trauma.
Look for a valid Wisconsin Do-not-resuscitate bracelet.
Skin: Warm/cold, dependent lividity, rash, ecchymosis?
HEENT: Airway patient, foreign bodies (e.g. dentures), neck swelling or trauma, trachea in midline, pupil size and response?
Chest: Spontaneous respirations, subcutaneous air or crepitation, or deformity?
Lungs: Equal breath sounds, difficulty bagging or ventilating?
Cardiovascular: Absence of heart sounds, carotid or femoral pulses?
Abdomen: Distended?
Extremities: Rigor mortis, edema, deformity?
Neurological: Unresponsive to verbal and painful stimulation?
Data Initial Cardiac rhythm, blood sugar, EtCO2, event audio and data
Goals of Therapy Return of spontaneous circulation (ROSC), provide adequate brain perfusion Monitoring Cardiac Monitoring, Vital Signs, and SpO2, EtCO2
EMERGENCY MEDICAL RESPONDER/EMT
• A CODE COMMANDER should assign duties according to MCMAID prior to arrival
• Establish that the patient is unresponsive, and not breathing normally
• Rule out DNR status, dependent lividity, rigor mortis
• First Priority:
M -
(metronome) Quality Chest Compressions o Turn on Metronome, ensuring a rate of 100/minuteo Initiate 2 minutes of chest compressions, pediatric-follow AHA 2005 Guidelines
• Second Priority:
C-
(compressions) Quality Chest Compressionso Assign two compressors switching every minute, checking each others quality
(pediatric patient >1 yr , use peds pads up to 8 yrs if available if not use adult pads) o Manual, charge max joules during CPR, analyzing for no more than 5 sec (EMT-I/P)
(pediatric 4 joules/kg)
o Immediately resume 2 more minutes of compressions
• Fourth Priority:
A-
(airway)o Oropharyngeal airway and 10 liters O2 via NRB mask o Check patency if chocking is suspected
o No ventilations until after 3 cycles, unless pediatric-follow AHA 2005 Guidelines o CombiTube/ET after 3 cycles of compressions, unless 1st rhythm is nonshockable, then
as soon as possible, ventilate at 6/minute only enough volume to just make chest rise
• If ROSC, acquire 12-Lead EKG, ***ACUTE MI SUSPECTED*** see STEMI Guidelines
.
Give a status report to the ambulance crew by radio ASAP and ensure ALS has been dispatched.
AEMT
• Fourth Priority:
I-
(IV) Establish venous accesso Initiate IO 0.9% Normal Saline unless IV is assured and quick, run wide open (20ml/kg boluses for pediatric patients)
o Consider second IV and chilling both for unresponsive ROSC. Refer to Therapeutic Hypothermia Procedure
INTERMEDIATE
• Monitor basic rescuer interventions closely, ensure quality, uninterrupted chest compressions
• Fifth Priority:
D-
(drugs) Proceed to ACLS resuscitation medications o Obtain venous access, if not already doneo Epinephrine 1:10,000 1 mg IV/IO every other cycle of compressions (4 minutes) o Vasopressin 40 units IV/IO, repeat dose in 10 minutes if no ROSC
• If multiple shocks have been given, Amiodarone (Cordarone) 300 mg IV/IO, followed by another 150 mg if still refractory (shocks being delivered)
• After 3 cycles of compressions, (unless first rhythm in non shockable) place advanced airway without interrupting compressions and begin ventilations at 6/minute, using only the volume to just make the chest rise.
• If initially non-shockable, Identify and correct reversible causes: The Five H’s and the Five T’s o This applies mostly to PEA, but to a lesser extent, Asystole, as well.
o If rate is <60, Atropine Sulfate 1 mg IV. Repeat every 3 – 5 min to a maximum of 3 mg o “The Five H’s” (treatment orders are in parentheses)
Hypovolemia (Infuse Normal Saline wide open)
Hypoxia (Place an advanced airway and administer high-flow oxygen at a ventilation rate of 6/minute with only enough volume to make chest rise. [1])
Hydrogen Ion, i.e. acidosis (Perform ventilation [1])
Hyperkalemia [2]
• Give Calcium Chloride (10%) 1000mg IV over 2 – 5 minutes. May repeat X 1
• Give Sodium Bicarbonate (8.4%) 50 mEq IV
• Give Albuterol Sulfate 2.5 mg HHN may repeat X 1
• Hypokalemia (not treated in the field.)
Hypothermia (See Hypothermia & Frostbite Guidelines) o “The Five T’s” (treatment orders are in parentheses)
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Tablets (See Toxic Exposure/Overdose Guidelines)
Tamponade (EMT-P: Perform Pericardiocentesis)
Tension pneumothorax (Perform needle decompression)
Thrombosis, cardiac i.e. myocardial infarction (See Chest Pain Guidelines)
Thrombosis, pulmonary i.e. pulmonary embolism (No specific pre-hospital treatment available)
• If there is ROSC, as seen as a sudden large increase in EtCO2 and/or patient movement
o Give Amiodarone (Cordarone) 150 mg IV/IO over 10 minutes, if multiple shocks given o Reassess the need for airway devices
• Maintain advanced airway, if the patient remains unconscious
• If the patient wakes up, the airway may be removed. Use the procedures for removing advanced airway devices in the Respiratory Distress Guidelines.
o Monitor patient’s EtCO2 and ventilate accordingly (12-20 per minute to maintain EtCO2 around 35 mmHg)
o Maintain SBP >80 mmHg, Consider Dopamine Hydrochloride 10-20mcg/kg/minute IV infusion
o Consider inducing hypothermia, See Therapeutic Hypothermic Guidelines
• Consider RSI See Respiratory Distress Guidelines
• If post-resuscitation 12-lead EKG shows STEMI refer to STEMI Guidelines Contact Medical Control for the following:
• To discuss termination of resuscitation in the absence of a valid Wisconsin DNR Bracelet
• Additional medication orders
FOOTNOTES:
[1] Do not hyperventilate during cardiac arrest, even if hypoxia and acidosis are suspected causes. Strictly follow the ventilation guidelines described above.
[2] Suspect Hyperkalemia when patients with a history of chronic renal failure (dialysis patients) develop cardiac arrest. Pre-arrest history may include weakness, missed dialysis appointment(s), vomiting, concurrent illness, and T waves that are peaked and as large as the R wave.