Thus far, this issue has not arised in the course of the CICM general fellowship exam. It would not be unexpected, however. Various other paediatric and neonatal topics have previously appeared, and though they have received fairly peripheral treatment even in the college model answers, we can expect that cardiopulmonary resuscitation is a topic with sufficient value to merit a detailed and thoughtful exploration.
For the disinterested adult intensivist, the best reference for paediatric resuscitation would have to be the canonic Chapter 113 from Oh's Manual (p. 1158), "Paediatric cardiopulmonary resuscitation" by James Tibballs. The recommendations made in that chapter are based on the 2010 ILCOR guidelines ( "Part 10: Pediatric Basic and Advanced Life Support"). As far as this author is aware, they have not been revised since this edition.
Unique aspects of paediatric cardiopulmonary resuscitation
- Airways are smaller: for manual first responders, mouth to mouth-and-nose breaths are recommended.
- Children typically arrest beause of hypoxia or hypotension
- You need not have a pulseless infant to start chest compressions; if they are bradycardic to below 60, CPR should commence.
- In all sized children, the depth of compression is one third of the AP diameter- but the technique changes: from
- "Two finger" technique for neonates, for single rescuers
- "Both thumbs" technique for neonates, for traine group rescuers (the hands encircle the chest)
- For oung chindren, the heel of one hand may be used
- For neonates, the rate of compressions is 120/min
- Defibrillators need paediatric paddles for children who are smaller than 10kg (these are electrodes with 12-20 cm2 area).
- For haemodynamically unstable peri-arrest arhrythmias, the drugs are very similar to an adult selection, with the exception of verapimil. Calcium channel blockers like verapimil should not be used in infants or children, as they may induce cardiac depression and circulatory failure.
For the purpose of improving candidate recall under exam stress conditions, here are some paediatric resuscitation drug doses, derived from various tables in Oh's Manual as well as various forgotten sources lost in the course of this authors' haphazard referencing systems.
|Drug||Dose||for 3kg neonate||for 10kg infant||For 20kg primary schooler|
|Defibrillation energy||4 J/kg||12 J||40 J||80 J|
|Adrenaline||10 mcg/kg||30 mcg||100 mcg||200 mcg|
|Amiodarone||5 mg/kg||15 mg||50 mg||100 mg|
|Glucose 50%||1 ml/kg||3 ml||10 ml||20 ml|
|Maximum replacement rates for commonly used electrolytes|
|Potassium||0.3 mmol/kg/hr||0.9 mmol/hr||3 mmol/hr||6 mmol/hr|
|Sodium (3% saline)||0.5 ml/kg/hr||1.5 ml/hr||5 ml/hr||10 ml/hr|
|Magnesium||0.4 mmol/kg/hr||1.2 mmol/hr||4 mmol/hr||8 mmol/hr|
|Calcium chloride 10%||0.2 ml/kg||0.6 ml||2 ml||4 ml|
Endotracheal tube calculations:
Four formulae need to be recalled:
- Uncuffed tube diameter: size (mm) = age (years) / 4 + 4
- Cuffed tube diameter: size(mm) = age (years) / 4 + 3.5
- Depth of insertion (cm) for ETT = age (years) / 2 + 12
- Depth for a nasal tube (cm) = age (years) / 2 + 15
Circulatory access and volume resuscitation
- In infants, scalp veins are fair go.
- The umbilical vein can be used up to 1 week after birth.
- Intraosseous access should be established as soon as it is clear that other forms of access are going to be too fiddly or too difficult.
- Oh's Manual recommends the use of a 10ml syringe attached to a three-way tap as the best method of achieving rapid boluses of controlled volume.