Week 21: Pediatric Resuscitation!

Placental abruption may cause severe anemia and hypovolemia. This situation requires volume expansion and/or blood. Immediate O negative blood transfusion may be lifesaving. When intravenous access cannot be established and vascular access is needed, the umbilical vein is the most accessible site. Using sterile technique, a tie is placed around the base of the umbilical stump to control bleeding, and a scalpel is used to cut the cord 0.5 to 1 cm above the skin. The umbilical vein (always at the 12:00 o’clock position toward the head) is easily distinguished from the two smaller arteries, which are usually constricted. Flush a sterile 3.5F (premature) or 5.0F (term) umbilical venous catheter with normal saline and attach it to a three-way stopcock. The catheter is advanced into the umbilical vein just below the skin level until good blood return is obtained (usually of 2 to 4 cm). When other means of vascular access are not available, the intraosseous route may be attempted, as can a cut-down saphenous line; however the latter use is not common. Placing a line into the soft tissue of the lower back (clysis) was used prior to the advent of intravascular techniques.

The initial steps of newborn resuscitation are position, clear airway (including tracheal suctioning if necessary), dry, remove linen, reposition, administer oxygen as necessary, then simultaneously evaluate the infant’s respiratory effort, heart rate (HR), and color. Spontaneous respiratory effort is adequate if the infant is able to maintain his HR above 100 beats/minute and becomes pink. Following delivery, most infants respond to initial resuscitation by crying, with the heart rate immediately rising, and the patient gradually becoming pink. Some infants, however, require additional brief stimulation and 100% free-flow oxygen. Infants who remain apneic throughout the initial steps or who have gasping respirations require PPV with bag–mask ventilation with 100% oxygen. Ventilate for about 30 seconds, then reassess. In the uncompromised infant, the HR should remain greater than 100 beats/minute. A HR less than 100 needs to be closely monitored and PPV initiated (or continued). If the HR remains less than 60, further intervention with chest compressions, medications, and appropriate diagnostic evaluation is indicated. Therefore, in this patient, PPV should be continued and he should be closely observed. If the patient’s HR becomes less than 60, chest compressions should begin. Intubation may be necessary if the patient remains apneic. Epinephrine is recommended for asystole or bradycardia (HR less than 60) if not responsive to PPV with 100% oxygen and chest compressions for a minimum of 30 seconds.

This patient has acrocyanosis, which is a transient blue discoloration of the hands and feet when a newborn is cold. The perioral region can also be involved; however, it should not involve the lips and mucous membranes as this would be more indicative of true cyanosis. Acrocyanosis is a benign, self-limited condition that must be differentiated from true cyanosis, where the mucous membranes are also blue. Given that the remainder of this patient’s exam is normal, the oxygen saturation by pulse oximetry should be in the normal neonatal range of >94% and should not be associated with arterial desaturation.

Readings of 64%–73% (A), 74%–83% (B), 84%–93% (C) are indicative of hypoxia.

Rapid sequence intubation (RSI) is the preferred and most successful method of intubation in children. Medications used for RSI include an induction agent and a paralytic. The most commonly used induction agents are etomidate, ketamine, and propofol. Etomidate (0.3 mg/kg) preserves hemodynamic stability making it useful in hypotensive trauma patients. Ketamine (1-2 mg/kg) preserves respiratory drive and is a bronchodilator and cardiovascular stimulant making it an ideal drug for intubation in asthma and sepsis. Propofol (1-2 mg/kg) can also be used but may cause hypotension. Succinylcholine and rocuronium are paralytic agents used in RSI. Succinylcholine (1-2 mg/kg) is a depolarizing agent that has a shorter duration than rocuronium, but may cause hyperkalemia and bradycardia. Rocuronium (1 mg/kg) is a nondepolarizing agent that has a longer time to onset and longer duration than succinylcholine. In this asthmatic child, the preferred medications include ketamine and rocuronium.

Laryngeal stimulation associated with intubation can result in reflex bradycardia in children. Pretreatment with atropine (A) was the standard for all rapid sequence intubations, but is no longer recommended. Etomidate and rocuronium (B) could be used for intubation of this child, but the correct dose of etomidate is 0.3 mg/kg. Ketamine and succinylcholine (D) could also be used, however, the correct dose of succinylcholine is 1-2 mg/kg.

Intraosseous (IO) lines can be used as first-line access in a patient in cardiopulmonary arrest and is second-line access (after 90 seconds of peripheral access attempt or 3 attempts) in a critically ill patient, such as the one described in this vignette. IO lines are also reasonable in nonemergent situations when multiple IV access attempts have failed. After the line is placed, signs that confirm accurate placement include aspiration of bone marrow, fluid infuses without extravasation, and needle stands alone without support. However, imaging is not required for placement confirmation, although it can be done with an ultrasound. The IO line may be used immediately to administer fluids and medications as well as draw labs. Several studies have compared lab values obtained from venous blood samples to bone marrow samples from IO lines. Studies have shown poor correlation with white blood cell (WBC) count, platelets, AST, ALT, potassium, and ionized calcium.

Studies have shown good correlation between peripheral venous samples and IO samples for the following: glucose (A), hemoglobin, hematocrit (B), chloride (C), BUN, creatinine, serum drug levels, cultures, pH, PCO2, and blood/Rh type. There are conflicting data regarding the correlation with potassium.

Umbilical vein catheterization is an essential procedure in the resuscitation of the newborn. It is preferred over the umbilical artery in an emergency because cannulating the vein is technically easier. The umbilical vein may remain patent for approximately one week after birth and can be used for exchange transfusions and short-term central venous access.

The umbilical vein is technically easier to cannulate (A) and is therefore the recommended structure for access in an emergent setting. The lone umbilical vein (B) is located in the 12 o’clock position and is thin-walled. There are two thick-walled umbilical arteries (D) located at the 5 o’clock and 7 o’clock positions.

Vascular access (IO or IV) is the preferred method for drug delivery during CPR. But if it is not possible, lipid-soluble drugs such as Lidocaine, Atropine, Naloxone and Epinephrine (mnemonic LANE) can be administered via an endotracheal tube. However, the effects may not be uniform with tracheal as compared with intravenous administration. Optimal endotracheal doses of medications are unknown; in general, expert consensus recommends doubling or tripling the dose of lidocaine, atropine, or naloxone given via the ETT. For epinephrine, a dose 10x the intravenous dose (0.1 mg/kg or 0.1 mL/kg of 1:1000 concentration) is recommended. The effectiveness of endotracheal epinephrine during cardiac arrest is controversial. Some studies have shown it to be as effective as vascular administration; other studies have not found it to be as effective.

Non-lipid-soluble drugs such as adenosine (A), calcium gluconate (B), and sodium bicarbonate (D) may injure the airway and should not be administered via the endotracheal route.

There are important differences between the pediatric and adult airway that need to be taken into consideration when performing intubation. The pediatric epiglottis is longer, narrower, and shaped differently (omega) than the adult epiglottis. This makes direct laryngoscopy more difficult because the angle between the base of the tongue and the glottis opening is more acute. The epiglottis in the infant and young child (up to about eight years of age) is more easily picked up by a straight (e.g., Miller) blade.

The mucosa (B) is more vulnerable in infants, not adults. Minor trauma with the laryngoscope can lead to bleeding, which can worsen visualization of the airway. The narrowest portion of the trachea (C) is below the vocal cords in infants. This is why uncuffed tubes are used in the pediatric population. The risk of mainstem intubation (D) is greater in pediatrics due to the existence of a short trachea and bronchus.

Approximately 10% of newborns require some resuscitative assistance at birth, and approximately 1% require more advanced resuscitative measures. Bradycardia in the newborn (HR <100) usually reflects inadequate ventilation with poor oxygenation and is a major indicator of hypoxia. If there is no meconium present and the infant is bradycardic and apneic, positive-pressure ventilation should be initiated. Initially, this can be achieved with a bag mask, but endotracheal intubation should be considered if ongoing resuscitation is required. The first breaths may require higher pressure to remove lung fluid and to get the chest to rise.

Atropine (A) has no role in neonatal resuscitation. The pediatric heart is regulated by sympathetic, not vagally mediated, tone. Epinephrine (B) and chest compressions (C) should be administered if the HR drops below 60.