Paediatric Resuscitation

Most people learn by doing, whether their "doing" is simulation, or real life. Given the thankful infrequency of paediatric arrests, we must rely on simulation. I would strongly recommend you practice paediatric resuscitation simulations, making them as realistic as possible, to supplement your theoretical knowledge. I've heard that one children's hospital runs a mock paediatric arrest weekly, and it is very helpful.

Course wise, either APLS or EPLS is accepted. Most people I've spoken to prefer the APLS course as they syllabus is broader. I've not done both of them so I can't comment, but I enjoyed my course.

Guidelines
American Heart BLS guidelines
American Heart ALS guidelines
American Heart ALS and BLS
American Heart Summary
Anaethetists Update
Resus Council Guidelines

Issues
This blog has a look at what goes wrong in a paediatric arrest. With a link to a formal study, they conclude that "issues regarding equipment familiarity/use/misuse, failure to check BSL, and drug errors. Calculations of drug doses were difficult under stress. Failure rates in some of these domains exceeded 50%.

Drug dosing is difficult. Multiple smart phone apps exist - I like PalmPedi, despite the American-ness (if you buy PalmPedi consider getting PalmEM - reviewed on LITFL instead, as PalmED encorporates PalmPedi). This Australian website is nice and clear. We'll blog about drugs later.

Word of mouth suggests that "WET FAG" is no longer used as an acronym, and "WET FLAG" is more common instead. I do try and memorise all of these doses, but do like to be able to swiftly check them. I do not trust my phone to have signal or battery, and other Clinicians are often busy - so I rely on paper versions instead.

Parents - in or out?  In my experience they want to be in, and it is useful to have someone explaining things to them. They don't alter efficacy of the resuscitation effort.

Paeds arrest in trauma? Survival rates aren't good.

And debriefing afterwards is good, even if the resus is successful. Remember to carefully document - especially as you may have caused rib fractures, which may be later attributed to non accidental injury.

The Algorithm
Apart from doses, the algorithm is pretty much the same as for adults with a few key differences:
 - Start with 5 initial rescue breaths
 - CPR ratio 15:2

There are plenty of similarities:
 - No atropine unless bradycardic
 - Sodium bicarbonate only recommended if prolonged arrest, or associated with hyperkalaemia or TCA overdose
 - Continuous compressions encouraged.
 - After ROSC, titrate oxygen to saturations

Royal College of Paediatrics and Child Health

The RSPH has produced a guideline, which CEM has approved. Most of it doesn't affect us, as Emergency Providers - but it is again, a very useful summary that emphasises the importance of sending blood for tryptase levels.

I think most EDs complete most things here, except some of the educational facets of the guideline.

The guideline states we should:

• refer to an allergy clinic directly, via the GP using a local clinic or by checking the BSACI website
• provide a basic prevention and treatment package that includes:
•  basic avoidance advice based on the suspected trigger(s) 
• provision and training in the use of an adrenaline injector
• provide access to patient/parent/carer support group information

 Most emergency departments I know would admit a patient with a suspected anaphylactic reaction and assume that Paediatricians provided the above follow up.


Above frame from: http://www.rcpch.ac.uk/allergy/anaphylaxis.

Resus Council Guidelines

The resus council guidelines are what we should follow for every resuscitation. The guidelines are clear, and have a good summary of all the doses. They are very useful.

As you can see below, the resus council website has many good resources for anaphylaxis (adult and child).

• The anaphylaxis information including doses
• The Anaphylaxis slides - a ready made teaching session!
• The protocol
• Podcasts and discussion about anaphylaxis

Above frame from: http://www.resus.org.uk/indx/search.asp?zoom_sort=0&zoom_query=anaphylaxis&zoom_per_page=10&zoom_and=