Which ONE of the following is TRUE in relation to the use of a defibrillator in children?
Answer: C: The optimal dose for safe and effective cardioversion or defibrillation in children is unknown. The new recommended initial dose of 2–4 J/kg reflects LOE III/IV showing lower success in termination of VF in children with 2 J/kg. Adult data clearly shows that long pauses in chest compressions required for stacked shocks are associated with worse resuscitation outcomes and so the recommendation for single shock followed by prompt resumption of CPR is emphasized.
The dose in VF arrest and pulseless VT is unsynchronized. Synchronized cardioversion for unstable VT, that is, VT with hypotension or evidence of poor perfusion, is the current recommended first therapeutic approach in children.
The safety of AEDs in infants <1 year is unknown but case reports have documented successful defibrillation using AEDs in infants. Many AED devices can safely and accurately distinguish between shockable and non-shockable rhythms in infants and adults. A manual defibrillator or an AED with paediatric attenuation capabilities is preferred for use in infants and small children. If a manual defibrillator is not available, an adult AED with dose attenuation to 50 J may be used in infants (≤1 year old) and children 1–8 years of age. If neither a manual defibrillator nor an adult AED with an attenuated energy level is available, an AED with an adult preset dose may be used. Children aged over 8 years may be treated with adult AED preset energy levels.
References:
A 3-year-old boy presents to the ED with septic shock. His respiratory rate (RR) is 55 with SaO2 of 89% in room air. His pulse rate is 33/min, capillary refill time is 4 seconds, and BP is un-recordable. He is lethargic but easily reusable and has a GCS of 13. Respiratory examination suggests a right-sided pneumonia. Resuscitation is initiated with BVM ventilation with 100% oxygen, which improves his SaO2 to 100%. An intravenous fluid bolus of normal saline is given and antibiotics administered. His HR remains at 33/min with un-recordable BP.
Which one of the following is the MOST appropriate next step?
Answer: D: The optimal timing for intubation of children in shock remains unclear. Individual case reports of children and adults with septic shock suggest potential beneficial effects of early intubation.
There are no studies specifically investigating the role of intubation and assisted ventilation before the onset of respiratory failure in infants and children with shock. The decision to initially stabilise the patient according to a sepsis protocol, which may include early use of inotropes, is a case-by-case decision. Early intubation and mechanical ventilation will decrease the work of breathing and lessen metabolic demand, as well as decrease afterload. However, intubation of a critically unwell child always has the potential for precipitating critical hypotension with cardiac arrest.
Parasympathetic cardiac blockade with atropine may be indicated if bradycardia is caused by vagal stimulation or cholinergic drug toxicity. The IV or IO dose is 20 mcg/kg (Class A; Expert Consensus Opinion) and the ETT dose 30 mcg/kg. Bradycardia caused by hypoxaemia should be treated with ventilation and oxygen but, if unresponsive, should be treated with adrenaline. Severe bradycardia and/ or bradycardia with hypotension should be treated with adrenaline, not atropine.
Regarding the use of IO cannulae to establish circulatory access during resuscitation, which ONE of the following is TRUE?
Answer: C: IO insertion has a complication rate of <1%. IO insertion has been rigorously studied in preterm babies and its use is effective and safe. Multiple studies have shown there is no risk to bone growth, damage to the epiphyseal plate is not a common complication, and growth failure is not reported solely on the basis of IO use.
Regarding neonatal resuscitation, which ONE of the following is TRUE?
Answer: C Newborn infants who are born at term with clear amniotic fluid, who are breathing or crying with good tone, must be dried and kept warm and do not require resuscitation. Any deviation from this normal state requires careful, staged assessment to determine whether the following actions are needed in sequence:
Initial steps in stabilization (clearing the airway, positioning, stimulating with drying)
Ventilation
Chest compressions
Medications or volume expansion Progression from one stage to the next is based on simultaneous assessment of three vital signs:
Thirty seconds is allotted to complete one stage successfully, reevaluate, and decide whether to progress to the next. After the initial steps in stabilization have been performed and assessment of the heart rate reveals a rate below 100 bpm, positive pressure ventilation is required.
Full-term babies who are depressed in terms of crying, breathing or tone immediately after birth should have their airway cleared, be stimulated and dried, then reassessed before commencing with formal resuscitative steps. Additionally, the ILCOR guidelines clearly state that if resuscitation is required: ‘There is currently insufficient evidence to specify the concentration of oxygen to be used at initiation of resuscitation.’ The reason for this is that there is conflicting evidence on whether room air is better than 100% oxygen, and there is evidence that providing oxygen in this setting may cause tissue damage from free oxygen radicals.
There is no indication to suction a newborn who is showing vigorous signs of life, and who is crying and breathing spontaneously.
Auscultation of the heart is the most accurate clinical measure, with palpation of the umbilical cord less so. However, both are relatively insensitive. Several studies have addressed the accuracy of pulse oximetry in measuring heart rate in the delivery room. Pulse oximetry (SpO2) and heart rate can be measured reliably after 90 seconds from birth with a pulse oximeter designed to reduce movement artifact and a neonatal probe (LOE 4).
Reference:
In assessing the initial need for resuscitation of a newborn, which ONE of the following is the BEST option?
Answer: C: The need for resuscitation is determined by repeated and staged assessment of heart rate, respiration and colour in 30-second stages. Apgar scores are measured at 1 and 5 minutes and therefore are useless as a resuscitation assessment tool. The use of the Apgar score is limited to reviewing a neonate’s response to initial successful resuscitation. The probe should be attached to the right hand or wrist.
Heart rate should remain the primary vital sign by which to judge the need for and efficacy of resuscitation. Auscultation of the precordium should remain the primary means of assessing heart rate. There is a high likelihood of underestimating heart rate with palpation of the umbilical pulse, but this is preferable to other palpation locations. For babies who require ongoing resuscitation or respiratory support or both, the goal should be to use pulse oximetry. The sensor should be placed on the baby’s right hand or wrist before connecting the probe to the instrument. Because of concerns about the ability to consistently obtain accurate measurements, pulse oximetry should be used in conjunction with and should not replace clinical assessment of heart rate during newborn resuscitation. Furthermore, saturation monitoring is inconsistent in the first 90 seconds after birth – precisely the period during which heart rate assessment is needed to determine the need for resuscitation.
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