Paediatric resuscitation in specific circumstances

Teamwork in critical care management

Paediatric resuscitation involves a series of critical decisions and procedures which should be performed rapidly and safely with the aim of stabilising and/or reversing clinical deterioration in a child. As these critical procedures (e.g. endotracheal intubation) are performed in the seriously unwell child, management should also be focused upon avoiding further clinical deterioration and cardiac arrest.

The individuals, the team and the environment should all be prepared. Crisis resource management principles should be followed:

• An appropriate team with the appropriate knowledge and skills should be assembled.

• Appropriate roles should be allocated to team members.

• Emergency equipment and medication requirements should be anticipated and prepared.

• The team leader should brief the team before any critical resuscitation/procedure and perform regular recaps with the team during the resuscitation/procedure. This promotes team member involvement in a shared mental model.

• Briefs/recaps should include:

  • A brief summary of the current situation.

  • Anticipated priority actions and their requirements.

  • Allocation/reallocation of roles according to expected needs.

  • Consideration of potential unexpected complications and planning for these.

Use of checklists, closed-loop communication and fostering a shared culture of safety in organisations are likely to help in this regard.

Rapid sequence induction in critical situations

In shocked or hypotensive children who may already be at the limit of their cardiovascular compensation, modification of rapid sequence induction (RSI) is required. Deterioration during RSI should be anticipated due to the effect of vasodilating induction drugs, loss of endogenous catecholamine effects, and loss of spontaneous breathing that aids venous return. RSI drugs with vasodilating or negative inotropic effects (such as propofol and thiopentone) should generally be avoided or their dose substantially reduced. Higher doses of muscle relaxant (upper end of dose range) should be used to ensure reliable effect in a compromised circulation. The potential need for vasopressor/inotrope infusions should be anticipated. These should be prepared or commenced prior to commencing the procedure (see also Chapter 29.4 ).

Resuscitation of children with congenital cardiac disease

Although infants and children with congenital heart disease (including hypoplastic left heart syndrome, cavopulmonary shunts or pulmonary hypertension) may require special considerations during resuscitation, standard cardiopulmonary resuscitation (CPR) techniques should be used initially while seeking specialist advice. ^,

Standard resuscitative techniques may be ineffective in cardiac arrest in children with pulmonary hypertension. In this setting, reversible causes of increased pulmonary vascular resistance (cessation of medication, hypoxia, hypercarbia, cardiac arrhythmias, cardiac tamponade, drug toxicity) should be sought and treated. Treatment with pulmonary vasodilators should be considered in combination with CPR. If these are ineffective, extracorporeal membrane oxygenation (ECMO) may be lifesaving in centres where it is readily available.

Anaphylaxis

Cardiac arrest secondary to anaphylaxis is rare in children and management should follow standard arrest algorithms. Aggressive and early management of acute anaphylaxis is lifesaving. Adrenaline is the first line medication used to manage angioedema, bronchospasm and shock from anaphylaxis (see Chapter 24.5 ). Adrenaline should be given via the intramuscular route initially. In severe or resistant cases, adrenaline should be given intravenously. Multiple intravenous or intraosseous boluses of 10–20 mL/kg of crystalloid fluid may be required to improve intravascular volume state and counteract vasodilation. Angioedema may contribute to airway obstruction and make endotracheal intubation very difficult.