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In this lesson, we'll cover pulseless arrest, including the two types of pulseless arrest, and how to treat for the most common type – ventricular fibrillation, or VFib.
Pulseless arrest is one of the more anxious situations for most healthcare providers, particularly when it involves pediatric patients. VFib and ventricular tachycardia, or V-tach, are both lethal dysrhythmias that do not produce a pulse.
Trauma, or severe injuries, are one of the leading causes of out-of-hospital cardiac arrest in children. Even so, the treatment for pediatric trauma victims in cardiac arrest is the same as it is for children in non-traumatic cardiac arrest. Which is to support the patient's ABCs:
Pro Tip #1: In pediatric cases where the arrest is due to a mechanical form of shock and in which treatment can be performed immediately to relieve the cause of the obstructive shock, you should still follow the same algorithm.
VFib is the most common initial dysrhythmia in cardiac arrest patients and will regress further to asystole if it isn't immediately treated.
The key steps to treating VFib are as follows:
Pro Tip #2: Delivering a first shock as soon as possible is extremely important, as statistically, every minute that defibrillation is delayed, the chance of survival is reduced by about 10 percent.
As a healthcare professional, providing high quality CPR is always a priority. But for a child or infant, high quality CPR needs to be performed with as few interruptions as possible.
This means a number of things, but it starts with giving cycles of 15 chest compressions at a depth of 1/3 the depth of the chest and at a rate of 100 to 120 compressions per minute.
This should be followed by 2 rescue breaths, and make sure it's enough to get the patient's chest to rise and fall.
Chest compression depth will vary based on the patient's size, so these are merely averages:
Child chest compressions – about 2 inches in depth.
Infant chest compressions – about 1.5 inches in depth.
Pro Tip #3: To ensure the quality of CPR being performed remains high, change the compressor every 2 minutes – or sooner if needed – to avoid fatigue, which often leads to less than optimal CPR compressions.
After the initial defibrillation shock has been delivered, an IV or IO needs to be established in order to administer medications.
The first medication given is epinephrine, and this should be administered using the 1:10,000 concentration at .01mg/kg via either IV or IO push every 3 to 5 minutes. And remember that a 20cc bolus of normal saline should be pushed after that to get the medication into the patient's circulatory system.
After the initial dose of epinephrine has been delivered, and after a second shock is given, consider placing an advanced airway with capnography. Also, once the advanced airway is in place, continue to perform high quality chest compressions at a rate of 100 to 120 per minute. And 1 rescue breath is given every 6 seconds synchronized with those compressions.
If the patient remains in persistent VFib after the initial shocks and epinephrine administration, the next medication to be given is amiodarone at 5mg/kg via rapid IV or IO push. Two more doses of amiodarone may be repeated.
The successful treatment of VFib continues with:
Pro Tip #4: Any pulseless arrest, such as VFib, V-tach, or even PEA and asystole, needs to include nearly continuous high-quality CPR. The ONLY thing that should interrupt CPR are brief rhythm checks.
Also important to note – you do not want to interrupt CPR to administer drugs. IV or IO administration of medications should be given while chest compressions are being performed in order to get the drugs circulated to the patient's heart and throughout their body, and to keep good circulation to their vital organs and tissues.
Aggressive and non-interrupted CPR has shown great improvement to pediatric patient outcomes, and more importantly, their improved post-resuscitation quality of life.