last part of PALS GUIDELINES , INCLUDE POST ARREST ACRE AND DRUGS

1. PEDIATRIC ADVANCED LIFE
SUPPORT 2017 GUIDELINES-
POST- ARREST CARE
DR. SAYED ISMAIL,MD
PROFESSOR AND CONSULTANT OF PEDIATRIC ALAZHAR
UNIVERISITY

2. Post arrest cardiac care
• Respiratory care to maintain normal O2sat 94-99%
• Cardiac care by inotropic e.g. milrinone , epinephrine
• Neurological care
• Ongoing assessment by evaluate , determine
intervene process

3. Respiratory care : Ventilation
• Maintaining the PaCO2 within a normal physiological range
• Oxygen
After ROSC, titrate the inspired oxygen, using pulse oximetry, to
achieve an oxygen saturation of 94–98%.
• Carbon dioxide
– The usual target range for PaCO2 in this setting is 35-40mmhg

4. Acute Cardiovascular care
• Avoiding and immediately correcting hypotension by
Intravascular fluids and inotropes
• Treat Hypotension
– Rationale: Maintain perfusion
– Fluid bolus if tolerated
– Dopamine 5–10 mcg/kg per min
– Norepinephrine 0.1–0.5 mcg/kg per min
– Epinephrine 0.1–0.5 mcg/kg per min
• Rescue and post-ROSC use of extracorporeal membrane
oxygenation (ECMO)

5. NEUROLOGICAL
• Anti-convulsants if seizing
• Prevent hyperpyrexia >37.7°C to Minimize
brain injury

6. METABOLIC
• Serial Lactate
– Rationale: Confirm adequate perfusion
• Avoid hypokalemia which promotes arrhythmias
• Detect hyperglycemia and hypoglycemia

7. Prognostic factors for outcomes of resuscitation
• No single prognostic factor is sufficiently reliable to inform
decisions about the termination of a resuscitation attempt or the
likely outcome
• Factors that should influence any decisions include the
circumstances of the arrest, initial rhythm, duration of
resuscitation and other features such as presence of hypothermia
and severe metabolic derangement.

8. Targeted temperature
• A child who has ROSC, but remains comatose after
cardiorespiratory arrest, may benefit either from being
cooled to a core temperature of 32–34°C (TH) or
having their core temperature actively maintained at
36.8°C for at least 24 h post arrest
• Do not actively rewarm a successfully resuscitated
child with hypothermia unless the core temperature is
below 32°C. Following a period of mild hypothermia,
rewarm the child slowly at 0.25–0.5°C h-1.

9. Blood glucose control
• Hyperglycaemia and hypoglycaemia should be
avoided following ROSC but tight glucose control has
not shown survival benefits when compared with
moderate glucose control in adults and increased the
risk of hypoglycaemia in neonates, children and
adults

10. Drugs

11. Dopamine
– Actions :
• dopaminergic effects: 1-3 mcg/kg/min, increased renal
perfusion and splanchnic blood flow.
• beta-1 effects: 4-10 mcg/kg/min, increased HR and
contractility.
• alpha-1 effects: 10-20 mcg/kg/min, vasoconstriction.
– Uses
• Hypotension or poor perfusion unresponsive to fluid
resuscitation.
• Side effects include tachycardia, dysrhythmias, hypertension,
extravasation necrosis (treat with Regitine).
• > 50% of dopamine’s action is indirect via nerve uptake and
conversion to norepi. Sick children may not have adequate
intrinsic catecholamine stores to release. Thus dopamine
may be ineffective, and epinephrine may be a better drug in
children with shock.

12. EPINEPHRIN
• Epinephrine is a potent α- and β-adrenergic stimulating .
• The α-adrenergic action increases systemic and pulmonary vascular resistance,
increasing both systolic and diastolic blood pressure. The rise in diastolic blood
pressure directly increases coronary perfusion pressure, thereby increasing the
likelihood of return of spontaneous circulation.
• The β-adrenergic effect increases myocardial contractility and heart rate and
relaxes smooth muscle in the skeletal muscle vascular bed and bronchi.
Epinephrine also increases the vigor and intensity of ventricular fibrillation,
increasing the likelihood of successful defibrillation.
• Larger than necessary doses of epinephrine may be harmful . Epinephrine may
worsen myocardial ischemic injury secondary to increased oxygen demand and
may result in postresuscitative tachyarrhythmias, hypertension, and pulmonary
edema.
• Prolonged peripheral vasoconstriction by excessive doses of epinephrine may
delay or impair reperfusion of systemic organs, particularly the kidneys and
gastrointestinal tract.
• Routine use of large dose epinephrine in in-hospital pediatric cardiac arrest should
be avoided

13. Epinephrine-
• The drug of choice in post arrest situations and in most pediatric
pateints with severe shock.
• Actions - Acts on alpha and beta receptors
– beta-1: 0.05-0.3 mcg/kg/min, increased HR and contractility.
– alpha-1: 0.3-5 mcg/kg/min, vasoconstiction
• Uses
– Cardiac arrest
– Shock , May be effective when dopamine is not
– Symptomatic infant or child with bradycardia unresponsive to
ventilation and oxygen administration.
• Precautions
– Similar to dopamine.

14. Epinephrine : Dose: 0.01 mg/kg IV/IO
(0.1 ml/kg of 1:10,000 concentration)
Continuous infusion
0.1 to 1 µg per kg per minute (continuous infusion)
preparation : 0.6mg/kg + 100ml - D5
Iml/hr = 0.1µg per kg per minute

16. Norepinephrine
• Actions - primarily alpha effect, increases systemic
vascular resistance.
• Used in shock with hypotension despite volume
resuscitation and adequate inotropic support. Sometimes
used as a first line vasopressor in septic shock (warm
shock)
• (Nor)adrenaline solutions should be 10 times diluted.
• Precautions - potential for decreased regional perfusion.

17. Dobutamine
• Actions-primarily Beta 1 effect
• increased HR, increased contractility, vasodilation.
• dose : 5-20 mcg/kg/min,
• Used for congestive heart failure or to treat
hypoperfusion associated with high vascular tone.
• Contraindicated in patients with hypotension.

18. Actions-a phosphodiesterase inhibitor, Milrinone exhibits both
inotropic and vasodilatory effects
• Used for CHF, cardiac dysfuction and afterload reductions
• and in shock with cardiac dysfuction and high vascular tone.
• Dose: 50 mcg/kg load, followed by infusion of 0.5-1mcg/kg/min.
• Precautions: Rarely causes thrombocytopenia. Potential for
hypotension.
Milrinone

19. Amiodarone
• Amiodarone is antiarrhythmic used to treat
ventricular tachycardia or ventricular
fibrillation

20. • Most useful drug for ventricular ectopy as it
decreases automaticity.
– Indications – V F, V T or symptomatic ventricular ectopy.
– Precautions:
• reduce the infusion rate in shock, CHF, cardiac arrest,
liver dysfunction.
• toxicity = myocardial/circulatory depression, CNS
symptoms include seizures.
Lidocaine

21. Atropine
Actions - parasympatholytic
Accelerates sinus/atrial pacemakers
Increases AV conduction
Indications
Vagally mediated bradycardia
Symptomatic bradycardia
Precautions
Smaller than vagolytic dose may cause paradoxical
bradycardia (min dose 0.1 mg).
May mask hypoxia induced bradycardia.