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ABC Management (Primary Survey)
Assess Responsiveness
Open Airway
Assess Breathing
Call for help and activate EMS
Position patient supine
Support head and neck
Look, Listen, Feel for breathing
Obstructed Airway
Perform Heimlich Maneuver
Obstructed Airway
Remove foreign body
Obstructed Airway
Assess Circulation
Pulse Present
Pulse Absent
Cycle back to attempt ventilation
Check Pulse
Perform rescue breathing
Observe for adequate chest rise
Tidal Volume: 10-15 ml/kg
Perform CPR
Infant CPR (<1 year old)
Child CPR(1-8 years old)
Adult CPR (over 8 years old)
Call for Crash Cart, Defibrillator
Head tilt-Chin lift
Jaw Thrust (if c-spine injury)
Attempt ventilation
If unsuccessful, reposition airway
Reattempt ventilation
Infant: 5 chest thrusts, 5 back blows
Child: 5 abdominal thrusts
Adult: 6-10 abdominal thrusts
Infant or Child: Identify obstruction
Adults: Blind finger sweep
Repeat until obstruction cleared
Infants: Brachial Pulse
Child or Adult: Carotid Pulse
Infant: 20 breaths per minute
Child: 15 breaths per minute
Adult: 12 breaths per minute
Hand Position: 2 fingers at nipple line
Rate: >100 times per minute
Depth: 0.5 to 1 inch
Ratio: 5 compressions to 1 breath
Reassess: every 10 cycles (45 seconds)
Hand Position: 1 hand above xiphoid
Rate: 80-100 times per minute
Depth: 1 to 1.5 inches
Ratio: 5 compressions to 1 breath
Reassess: every 10 cycles (60-87 seconds)
Hand Position: 2 hands above xiphoid
Rate: 80-100 times per minute
Depth: 1.5 to 2 inches
Ratio based on number of rescuers
One: 15 compressions to 2 breaths
Two: 5 compressions to 1 breath
Reassess based on number of rescuers
One: every 4 cycles (52-73 seconds)
Two: every 10 cycles (40-53 seconds)
Universal Interventions
Vital Signs
Systolic Blood Pressure
Respiratory Rate
Pulse
Oxygen Saturation
Mneumonic: 30-60/60-90/40-75
Intubation
Endotracheal Tube Size (id in mm)
Use a cuffed ET tube if age > 8
Audible air leak at 20-30 cm H20
Endotracheal Tube Depth
Oxygen Delivery
High Oxygen Concentration
Medium Oxygen Delivery
Low Oxygen Delivery
Shock Management
Intravenous Access
Initial IV fluids: Crystalloid
25% of crystalloid stays intravascular
Secondary IV fluids: Colloid, Blood
Shock refractory to crystalloid fluids
Median SBP: 90 mmHg + (2 x Age)
Minimum SBP: 70 mmHg + (2 x Age)
Normal: 80 Infant, 90 Preschool, 100 Teen
Normal: 40 Infant, 30 Preschool, 20 Teen
Respiratory Distress: >60 breaths per minute
Normal: 160 Infant, 120 Preschool, 100 Teen
30 PaO2 = 60% O2Sat
40 PaO2 = 75% O2Sat
60 PaO2 = 90% O2Sat
Newborn: 3.0 – 3.5 (term) 2.5 – 3.0 (preterm)
Child (Age>2): Age/4 + 4 (or Pinky finger size)
Adult: 7 - 8.0 mm (up to 8.5 in men)
Newborn: 9 – 10 cm (term) 8 cm (preterm)
Child (Age>2): Age/2 + 12 (or ET Size x 3cm)
Adult: 20-22 cm
95%: Non-Rebreather with reservoir (10-12 lpm)
90%: Oxygen Hood (10-15 lpm) for under age 1
60%: Partial Rebreather with reservoir (6-10 lpm)
60%: Venturi Mask (4-8 lpm)
60%: Simple Mask (6-10 lpm)
44%: Nasal Cannula (1-4 lpm)
40%: Face tent or shield (10-15 lpm)
Peripheral IV Access in 90 seconds
Umbilical Vein Catheter (UVC) for newborn
Intraosseous line for child under age 6 years
Femoral Line (Right: Nerve, Artery, Vein, Lymph)
Other Central Line: Jugular, Subclavian
Saphenous Vein Cutdown
Crystalloid: NS or LR Bolus (3-4 may be required)
Child: 20 cc/kg rapid IV bolus (<20 minutes)
Adult: 1 Liter rapid IV bolus (<20 minutes)
Colloid: 5% Albumin
Blood Products: pRBC
Arrhythmia Management
Universal Approach
Arrhythmia: Too Fast
Unstable
Narrow Complex
Wide Complex
ABC Management
IV-O2-Monitor
CPR as indicated
Consider Intubation
Intravenous Access
High-flow Oxygen Administration
Cardiac Monitor
Synchronized Cardioversion
Indications:
Narrow complex tachycardia
Wide complex tachycardia
Child
First dose: 0.5 Joules/kg
Subsequent doses: 1 Joules/kg
Adult
PSVT, Atrial Flutter: 50, 100, 200, 300, 360 J
VT, Atrial Fibrillation: 100, 200, 300, 360 J
Treat Underlying Cause
Fever, Hypovolemia, Hypoxia, Anxiety, Pain
Electrolyte abnormality, Drug Ingestion
Pneumothorax, Cardiac Tamponade
Vagal Maneuvers: Carotid massage or ice immersion
Adenosine
First: 0.1-0.2 mg/kg rapid IV (up to 6 mg)
Next: 0.2-0.4 mg/kg rapid IV (up to 12 mg)
Verapamil (Age over 8, no CHF or Hypotension)
First: 0.1 mg/kg (up to 2.5 mg) IV over 3 min
Next: 0.2 mg/kg (up tp 5.0 mg) IV over 3 min
Synchronized Cardioversion (See above)
Lidocaine
Bolus: 1 mg/kg IV
Infusion if bolus successful: 20-50 ug/kg/min
Synchronized Cardioversion (See Above)
Lidocaine
First: 1.0 - 1.5 mg/kg IV push, wait 3-5 min
Next: 0.5-0.75 mg/kg IV push (Max: 3 mg/kg)
Procainamide 20-30 mg/min (max: 17 mg/kg)
Bretylium 5-10 mg/kg over 10 minutes
Synchronized Cardioversion (See Above)
Epinephrine every 3-5 minutes
IV Dose: 0.01 mg/kg (0.1 ml/kg 1:10,000)
ET Dose: 0.1 mg/kg (0.1 ml/kg 1:1000)
Atropine: 0.02 mg/kg IV/ET (0.1-0.5 mg)
Transcutaneous Pacing
Do not shock Sinus Tachycardia
Sinus Tachycardia
P Waves present and normal
Constant PR interval
Heart rate below PSVT
Supraventricular Tachycardia (PSVT)
P Waves Absent or abnormal
Heart Rate above Sinus Tachycardia
Infants > 220 beats/minute
Children > 180 beats/minute
Adults > 160 beats/minute
Child Ventricular Tachycardia
Adult Ventricular Tachycardia
Arrhythmia: Too Slow
Arrhythmia: Pulseless
Shockable
Pulseless Electrical
Activity (PEA)
Asystole
Child Unstable Bradycardia
Adult Unstable Bradycardia
Atropine 0.5-1.0 mg IV/ET q5 min (to 0.04 mg/kg)
Transcutaneous pacing
Dopamine 5-20 ug/kg/min
Epinephrine 2-10 ug/min
Shockable Rhythms
Ventricular Fibrillation
Pulseless Ventricular Tachycardia
Defibrillate
Child: 2 j/kg, 4 j/kg, 4 j/kg
Adult: 200j, 300j, 360j
Epinephrine (repeat every 3-5 minutes)
Child: 0.01 mg/kg IV (0.1 mg/kg ET)
Adult: 1 mg IV (2.5 mg in 10 cc NS ET)
Defibrillate: 4 joules/kg (Adult: 360 Joules)
Lidocaine 1 mg/kg IV/IO
Defibrillate: 4 joules/kg (Adult: 360 Joules)
Bretylium 5-10 mg/kg
Defibrillate: 4 joules/kg (Adult: 360 Joules)
Child: Same treatment as for Asystole
Adult (Same treatment as for Asystole)
Epinephrine 1 mg IV push q3-5 minutes
Atropine 1 mg IV q3-5 minutes (max: 0.04 mg/kg)
Treat Cause: 4H TAPE MD
Hypoxemia, Hypovolemia,
Hypothermia, Hypokalemia,
Tension Pneumothorax,
Tamponade, Pulmonary Embolus,
Myocardial Infarction,
Drug Overdose
Treat Cause
Hypoxia, Hypothermia,
Hyperkalemia, Hypokalemia
Preexisting acidosis
Drug Overdose
Child: (Same treatment as for PEA)
Epinephrine first: 0.01 mg/kg IV (0.1 mg/kg ET)
Epinephrine next: 0.1 mg/kg IV or ET
Adult: Same Treatment as PEA (consider TCP)