Regarding current paediatric resuscitation guidelines in the pre-hospital and hospital environment, which ONE of the following statements is TRUE?
Answer: C: The ILCOR Neonatal Task Force recommends a compression-ventilation ratio of 3:1 for resuscitating newborns in the delivery room, with a pause for ventilation whether or not the infant has an advanced airway. It is unknown what the optimal compression-ventilation ratio is during CPR for all infants in the first month of life beyond the delivery room. If the aetiology of the arrest is cardiac, a 15:2 ratio (two rescuers) may be more effective than a 3:1 ratio. If it is suspected to be asphyxial or respiratory in nature, then 3:1 provides more effective ventilation, at the expense of interrupted CPR. The level of evidence (LOE) is poor at best (level 5). Generally, all infants beyond the immediate perinatal period should be managed according to paediatric guidelines. The Pediatric Task Force recommends a 15:2 compression-ventilation ratio with a pause for ventilation in infants without an advanced airway, and continuous compressions without a pause for ventilation for infants with an advanced airway. Traditionally, the initial mode of providing assisted positive pressure ventilation in critically unwell children has been via a BVM ventilation device. When definitive airway protection and invasive ventilation has been deemed necessary, endotracheal intubation using an endotracheal tube has been the next logical step. The laryngeal mask airway (LMA) has in recent years become a useful rescue airway technique, in whom intubation has proved difficult. No studies have directly compared BVM with the use of supraglottic airway devices during paediatric resuscitation other than for the newborns in the delivery room. Nine LOE 5 case reports demonstrated the effectiveness of supraglottic airway devices, primarily the LMA, for airway rescue of children with airway abnormalities. Unfortunately, in anaesthetic-based studies, complication rates with LMAs increase with decreasing patient age and size. In the intensive care unit (ICU) setting, time to effective ventilation was shorter and tidal volumes were greater with BVM. The ILCOR guidelines treatment recommendation on this issue is that BVM remains the preferred technique for emergency ventilation during the initial steps of paediatric resuscitation. In infants and children for whom BVM is unsuccessful, use of the LMA may be considered for either airway rescue or support of ventilation. LMAs should not be used in semiconscious patients or when the gag reflex is present. They are subject to dislodgment during transport. Their use should not replace mastery of BVM ventilation. Children older than 9 years of age may be managed according to adult resuscitation guidelines, although clinical judgement should be exercised in considering the child’s weight, height and developmental age.
Prevention of cardiopulmonary arrest in children is an important aspect of paediatric critical care. In this regard, which ONE of the following is FALSE?
Answer: C: Prevention of illness in children is a cardinal paediatric principle. Cardiorespiratory arrest in children is often preceded by a period of recognizable deteriorating respiratory function, and is usually respiratory or asphyxial in nature. This deterioration can readily be detected if systems are in place to recognise and treat this warning phase, therefore preventing cardiorespiratory arrest. METs have been shown to be effective in preventing respiratory and cardiac arrests in selected paediatric inpatient settings, although the LOE for MET teams is level III at best. The Australian Resuscitation Council recommends that all institutions that manage childhood illnesses should have a system enabling staff at the bedside to quickly summon expert help if needed (Recommendation Class A). One LOE I randomized controlled trial in children with severe sepsis or fluid refractory septic shock showed that protocol-driven therapy targeting a superior vena caval oxygen saturation of 70%, coupled with treating clinical signs of shock (prolonged capillary refill, reduced urine output and reduced blood pressure), improved patient survival to hospital discharge in comparison with standard treatment aimed at clinical signs alone. There are insufficient data regarding the use of lactate and pH to guide management of shock in children.
Regarding paediatric arrhythmia in the setting of critical illness and cardiorespiratory arrest, which ONE of the following is INCORRECT?
Answer: B: Cardiorespiratory arrest occurs in a wide variety of conditions among infants and children. The majority is caused by hypoxaemia, hypotension, or both. Examples are trauma, drowning, septicaemia, SIDS, asthma, upper airway obstruction and congenital anomalies of the heart and lung. The initial cardiac rhythm discovered during early electrocardiographic monitoring is often severe bradycardia or asystole. VF is much less common in children than in adults, with an incidence of primary VF in children of 10%. The optimal effective and safe dose of electricity to be used is unknown. The incidence of primary VF in children is 10%.
Seven LOE 3 studies showed that mutations causing channelopathies occurred in 2–10% of infants with SIDS, while one LOE 3 and two LOE 4 studies showed 14–20% of young adults with sudden death had genetic mutations causing channelopathies.
In recognizing cardiopulmonary arrest in infants and commencing appropriate CPR, which ONE of the following is TRUE?
Answer: D: Healthcare providers commonly assess pulse status inaccurately; they mistakenly palpate a pulse when it is non-existent or fail to detect a pulse when it is present. Additionally, pulse assessment often takes longer than 10 seconds. As a result, ILCOR suggests that palpation of a pulse (or its absence) is not reliable as the sole determinant of cardiac arrest and therefore decided to deemphasize but not eliminate the pulse check as part of the healthcare provider assessment. Current recommendations are that if the victim is unresponsive, not breathing normally, and there are no signs of life, lay rescuers should begin CPR. Healthcare providers should begin CPR unless they can definitely palpate a pulse within 10 seconds. CPR should be commenced promptly if doubt exists. The circulation may be assessed by palpation of a carotid, brachial or femoral pulse (Class B; Expert Consensus Opinion).
To be effective, chest compressions must be deep. The Australian Resuscitation Council recommends a chest compression depth of at least one-third of the anterior–posterior dimension of the chest or approximately 5 cm in children and approximately 4 cm in infants (Class A; Expert Consensus Opinion). The optimal method of chest compression, two-thumb or two-finger, is yet to be determined and either technique may be performed (Class A; LOE IV). However, the two-thumb technique is the strongly preferred technique for healthcare rescuers (Class A; Expert Consensus Opinion).
Approximately 50% of a compression cycle should be devoted to compression of the chest and 50% to relaxation to enable recoil of the chest wall.
Intravenous access during resuscitation is a vital part of management. Which ONE of the following is TRUE?
Answer: D: Intraosseous (IO) access in the setting of paediatric and adult resuscitative care is an old intervention that has found its way back into modern critical care. It provides faster and more reliable access than traditional peripheral routes when practitioners are trained in their use. The newer drill devices have not been prospectively shown to actually improve outcomes in paediatric resuscitation, but this question is posed as an area for future research in the ILCOR guidelines.
All resuscitative drugs and fluids may be given via the IV or IO route but only adrenaline, atropine and lignocaine are absorbed when given via ETT.
It is generally accepted that bone marrow may be reliably used for venous biochemical and haematological analysis but not for venous blood gas analysis. Most of the laboratory studies looking at IO samples have been done in animal settings. Recent data, however, suggests that white cell counts in IO samples are higher, and CO2 and platelet levels are lower, while most other analytes are similar.
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