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Post on 21-Feb-2017
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Dysrhythmias, Drugs, Drips, and Defibrillation
Pediatric ConsiderationsTerri M. Repasky MSN, RN, CEN, EMT-PClinical Nurse Specialist - Emergency
Dysrhythmias
• Rhythm disturbances are an uncommon cause of cardiovascular arrest in children
• In pediatrics we use three classes of rhythms
Rhythm group by pulse rate
• Slow pulse = bradyarrythmia
• Fast pulse = tachyarrhythmia
• Absent pulse = collapse rhythms
Slow Pulse
Fast Narrow Pulse
Fast Wide Pulse
NO Pulse
Things to Consider
• Is the patient stable or unstable ?
• Is the patient’s condition causing the rhythmOR is the rhythm causing the condition?
• Is the rhythm causing the patient to be unstable ?
Assessment of Cardiovascular Function
• Ventilation and Oxygenation
• Heart Rate
• End-organ perfusion
• Peripheral pulses
• Skin signs
• LOC
• Blood pressure
Pulses Blood Pressure
• Compensated Shock
• Hypotensive Shock
Blood Pressure
Cardiac Output = Heart Rate x Stroke Volume
Back to Pulses
• Is it fast, slow, or absent?• Is perfusion compromised?• Are the ventricular complexes wide or
narrow?• Is there a diagnostic pattern to the EKG?
Sinus Tachycardia
Supraventricular Tachycardia
Fast Pulse Narrow Ventricular Complex
• Sinus Tachycardia• Supraventricular Tachycardia
Fast Pulse Narrow Ventricular Complex
• Sinus Tachycardia
• Possible history of fever, pain, volume loss (diarrhea, vomiting, bleeding, trauma), anxiety, meds
• Supraventricular Tachycardia
• Nonspecific history of irritability, lethargy, poor feeding, tachypnea, sweating, pallor or hypothermia
Fast Pulse
• Tachycardia appropriate for the clinical condition
• Tachycardia excessive for the clinical condition
Fast Pulse
• Tachycardia appropriate for the clinical condition
• Sinus Tachycardia (ST)
• Tachycardia excessive for the clinical condition
• SupraVentricular Tachycardia (SVT)
Fast Pulse Narrow Ventricular Complex (QRS)
• Is it Supraventricular Tachycardia (SVT) or
• Sinus Tachycardia (ST) ???
Fast Pulse Narrow Ventricular Complex (QRS)
• Is it Supraventricular Tachycardia (SVT) or
• Sinus Tachycardia (ST) ???
History and Heart Rate are big clues
Fast Pulse Narrow Ventricular Complex
Heart Rate Probable SVT> 180 Children> 220 Infants
Fast Pulse Tachycardia excessive for the clinical condition
(not Sinus Tach)
Stable, Perfusing Patient
• Narrow QRS (probable SVT)
• Wide QRS (probable VT)
• Vagal Maneuvers• Adenosine• Expert Consultation• Amiodarone or
Procainamide• Treat possible contributing factors
• Expert Consult• Amiodarone or
Procainamide• Treat possible contributing factors
Fast Pulse Tachycardia excessive for the clinical condition
Unstable Patient, Poor Perfusion
• Narrow QRS (probable SVT)
• Wide QRS (probable VT)
• Synchronized Cardioversion• (may try Adenosine if it does not delay electrical cardioversion)
Fast Pulse Tachycardia appropriate for the clinical condition
• Consider the cause….
• Treat the cause !
Slow PulseStable Patient
Sinus Bradycardia Heart Blocks
• Consider the cause– Prolonged hypoxemia– Drugs
Slow Pulse
• Consider the cause:
• 6 H’s and 5 T’s Hypovolemia Hypoxemia“Hydrogen Ion” Hypothermia Hypoglycemia Hyper /Hypokalemia
Slow Pulse
• Consider the cause:
• more H’s:Head Injury Heart Block
Heart TransplantHeart Disease
Slow Pulse
• Consider the cause:
• 5 T’sTamponade Tension
PneumothoraxToxins Thrombosis
Trauma
Slow Pulse Unstable Patient, Poor Perfusion
• Oxygenation and Ventilation• Chest Compressions (if heart rate still <60 despite O2 & vents)
• Epinephrine• ? Atropine• Pace Maker
Slow Pulse
• Epinephrine vs Atropine
NO Pulse
• Asystole• Ventricular Fibrillation (VF)• Pulseless Ventricular Tachycardia (VT)• Pulseless Electrical Activity (PEA)
No Pulse
• CPR ? Defibrillate• Ventilate with 100% oxygen• IV or IO access• Epinephrine q 3-5 minutes
No PulseAsystole or PEA
• CPR• Ventilate with 100% oxygen• IV or IO access• Epinephrine q 3-5 minutes• Treat Cause!• Perform flat line protocol
No Pulse
• Flat Line Protocol–Check Leads–Check in a different lead–Increase gain or size
No Pulse
•Consider cause:
6 H’s and 5 T’s
No PulsePulseless Ventricular Tachycardia or Fibrillation
• CPR• Defibrillate (as soon as available)• Resume CPR• Rhythm Check (Q2mins), if VF/VT
• Defibrillate• Give Meds• Resume CPR
• Alternate Epi with Amiodarone
Summary of Therapy by Pulse Rate
Fast(adequate perfusion) Vagal Maneuvers, Adenosine or
Amiodarone/Procainamide(poor perfusion) Cardioversion
Slow Ventilation / Oxygenation CompressionsEpi.
Absent CPRVF / VT: DefibrillationPEA/EMD: Identify & treat the cause
Epinephrine
Warning:
Treat the Patient Not the Rhythm
Drugs & Drips
Fluids “Drips” are use for:Volume Replacement & Delivery of Medications
Drips: Fluids of Choice
• Isotonic Crystalloids–Normal Saline–Lactated Ringer’s
• What if your patient is hypoglycemic?
Drugs: Sites for Administration
Peripheral veinsIntraosseousCentral veinsEndotracheal
When would you use an IO ?
When would you use an IO ?
Cardiopulmonary ArrestShock
Intractable seizures
When would you use ET ?
• What drugs can you give down the ET tube?
• L or L• E A• A N• N E
How do I do that? • Dilute the drug with 3-5 ml of NS• Instill directly into tube • Deliver positive pressure breaths
• Or Insert a catheter into ET tube • Instill drug via catheter• Flush with 3-5 ml of normal saline• Deliver positive pressure breaths
1
2
Drugs Dosages: ET / IO
• IO: same dose as IV
• ET:– Epinephrine dose is 10 times greater
0.1 mg/kg (use 1:1,000 strength)– Other drug are increased 2-3 times IV dose
“ Defib.”
Joules per kilogram
Post Arrest Shock
Optimize Ventilation and Oxygenation
Titrate O2 saturation to 94% - 99%
Advanced Airway
Waveform Capnography
Treat shock&
Contributing Factors
Review
• Dysrhythmias - fast, slow, none
• Drugs - Oxygen, Epinephrine
• Drips - Normal Saline
• Defibrillation - rare but know how !
• Questions ????
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