Major Michael E. Mullins, MD, US Army
Tripler Army Medical Center
Honolulu, Hawaii

Children account for 25-35% of all ED visits. However, only 0.3% of these patients are critically ill or injured. ( APLS manual ) Rate of PICU admissions is 240 per 100,000 per year in the U.S. ( APLS manual ).

Most health care providers in emergency or primary care see few critical pediatric patients and have few opportunities to refine skills needed when minutes and seconds count.

We begin by reviewing the ABC's of resuscitation.

This lecture includes material from Pediatric Advanced Life Support( jointly sponsored by AAP and AHA ) and Advanced Pediatric Life Support ( jointly sponsored by AAP and ACEP). PALS focuses on cardiopulmonary arrest while APLS includes more specialized topics ( trauma, burns, DKA, toxicology, environmental injuries, seizures, etc. ).

This lecture does not replace PALS or APLS. Any health care provider responsible for care of infants and children should strongly consider taking either or both courses.

We shall briefly discuss the special topics of trauma, volume depletion, and burns since these affect fluid management of the critically ill child.

Since all drug dosages depend directly on the patient's weight, you must know or estimate the weight. Unstable patients need immediate attention and should not sit on a scale. Instead, if you know key average weights for certain ages, you can interpolate for in-between ages to be fairly close.
NB = 3.5 kg
6 mo. = 7 kg
1 yr = 10 kg ( add 2 kg for 2 yr ==> 12 kg)
4 yr = 17 ( subtract 2 kg for 3 yr ==> 15 kg )
Add 3kg per year above 4 yrs
5 yr = 20, 6 yr = 23 kg, ...etc.
10 yr = 35 kg

Since children vary around these averages, a Braselow Tape can also estimate weight and shows code drug doses.

You need to know maximal vital sign values to assist in identifying children in crisis. Vital signs exceeding those shown require immediate attention and corrective action.

Pulse does not always point to a fluid or circulatory problem. A hypoxic infant will often be tachycardia. Similarly a high respiratory rate does not always point to an airway/breathing problem. A volume-depleted toddler may well be tachypneic.

Every resuscitation requires the ABC's handled in this order.

In comparison to adults (ACLS), for whom the main problem is cardiac or circulatory, many pediatric codes are Airway/Breathing problems.

Basic methods to assure an open airway come first, as these are often enough.

If intubation is necessary, use this formula to select the right size endotracheal tube. However, be prepared to use a half-size larger or smaller. For example, a 2 yr old requires what size ET tube ?

(16 +2)/4 = 4.5 but if the airway is constricted, as in severe asthma, a 4.0 mm ( or smaller ) tube may be necessary.

Children under 8 yrs receive uncuffed ET tubes to avoid a delayed complication of subglottic stenosis. Remember that an uncuffed tube provides much less protection from aspiration than a cuffed tube would.

In extreme circumstances, a needle cricothyroidotomy may be necessary. This is simply involves piercing the membrane between the thyroid (Adam's apple) and the cricoid cartilage just below it.

With the Angiocath in place, an adapter taken from a 3.0-3.5 mm ET tube will fit in the hub.

Except in small children, wall oxygen connected to this will not provide adequate ventilation due to the relatively low pressure. A high-flow jet oxygen device is necessary to produce enough pressures to expand the chest and thereby to ventilate the patient. However, these devices are not available in many places.

Needle cricothyroidotomy is a temporizing measure used until a skilled surgeon can obtain a surgical airway.

Pediatricians often calculate maintenance fluids needed per day ( using the 100-50-25 rule) and then divide by 24. Emergency physicians generally think in minutes and hours, so we usually use the 4-2-1 rule. The final answer is the same.

Example : How much fluid does a 7 yr old child need ?
Remember the weight for 7 yrs is 26 kg.
10 kg X 4 ml/hr/kg + 10kg X 2ml/hr/kg + 6kg X 1ml/hr/ kg
40 + 20 + 6 = 66 ml/hr

If a child has other fluid requirements ( such as for trauma or burns ), do not forget to add the maintenance rate to the resuscitation fluids.

To replenish fluid volume ( lost due to trauma, vomiting+/- diarrhea, etc.), start with fluid boluses of 20 ml/kg.

How much does a typical 4 yr old need for a first bolus ?
Remeber that 4 yr olds= 17 kg. 20 ml/kg X 17 kg = 340 ml NS.

In trauma, the third bolus should be packed red blood cells at 10 ml/kg. (This same child will then get 10 ml/kg X 17kg = 170 ml PRBC's)

For adults the Rule of Nines is :
9 % BSA each for the head and each arm
18 % BSA each for the front of the torso, back torso, each leg
1 % BSA for the perineum/genitalia
In small children, the head accounts for a larger proportion of BSA and the legs account for smaller proportion of BSA.
18 % BSA for head, front torso, back torso
14% BSA for each leg
9% BSA for each arm
1% BSA for perineum/ genitalia

The Lund & Browder chart may more accurately estimate % BSA in children with adjustments in the proportions with age.

The palm of the hand is roughly equal to 1% BSA. This is an alternate way of estimating % BSA.

Parkland formula calculates fluid needed in the first 24 hrs from the burn. The modification gives the initial rate ( assuming a burned patient receives care immediately).

10% BSA burn in children 10 yrs old = burn admission.

IV is the preferred route for fluids. The techniques are familiar to many people, and IV's can permit large flow when needed.

Other options are interosseous infusion, venous cutdown, and central venous line ( in order of complexity ).

Take a moment to find the flat part of your own shin and the bump just below the knee to visualize where to place an IO line. Any drug that is approved for IV use can go into an IO line. However, for fluid resuscitation, IO lines achieve lower rates than IV lines since IO lines do not go directly into a vein.

Special IO needles are available, but many places do not stock these. Any needle with a trocar ( bone marrow needle, spinal needle, etc. ) will work as well. If these are not available, then almost any other needle will do although bone may clog these.

Although several veins are suitable for cutdown, the saphenous is popular because it is in a reliable location which is out of the way of other resuscitation efforts.

Take a moment to palpate the landmarks on your own ankle now to visualize the location for saphenous cutdown. The vein itself is easily collapsible so it may not be clearly noticeable by palpation.

This is a partial list of stat code drugs to remember. Because the mg/kg doses are often easily recalled incorrectly, many Emergency Departments keep a wall chart in the resuscitation room.

If you forget, and if you have no chart to use ( ie. in the field), you may use a " rule of thumb" :

Assume that an adult is 100kg, divide the adult ACLS dose by 100 to get the milligrams per kilogram. You will have to multiply by the child's weight. This is a close approximation to the correct dose for most drugs ( except Naloxone).

An alternate "rule of thumb " :

If an adult is 100 kg, divide the adult ACLS dose by 10 to get the dose for a 10 kg child. This will be fairly close for the child between 6 mos and 2 yrs.

Obviously, it is best to know doses well or have an immediately accessible reference chart in a code situation.

Defibrillation for V-fib or pulseless V-tach is 2 Joules/ kg. A Joule is also known as a Watt-sec. Compare this dose to the adult ACLS dose of 200 Joules as the initial energy level for defibrillation.

Synchronized Cardioversion is for unstable supraventricular tachycardia ( ie. narrow complex ) and ventricular tachycardia with a pulse ( ie. wide complex ). The initial dose is 0.5 to 1 Joule/kg. Compare this dose to the adult ACLS dose of 50-100 Joules for cardioversion.

In case you forget the pediatric doses but remember the adult ACLS doses, the "rules of thumb" for drug doses also apply to the electrical doses.

If you are still struggling to obtain vascular access and need to give medication immediately, these 5 medicines can be given through an ET tube.

Some sources recommend increasing the dose of Epinephrine to 0.02-0.03 mg/kg for ET doses ( 2-3 times IV dose).

If a child is seizing, an IV may be very difficult to obtain. However, diazepam (Valium) works even when given via ET tube. Diazepam also works when given per rectum.

Some people us a Rule of Six in preparing IV drips of certain code medications. Multiply the patient's weight by 6 ( for Lidocaine, Dopamine, Dobutamine ) or 0.6 ( for Epinephrine or Isoproterenol ) . Add this quantity of drug to 100 ml of D5W. This makes the mcg/kg/min drug flow rates come out to 1 ml/hr increments.

This is a review of the "inverted pyramid " of neonatal resuscitation. Many neonates respond to the first level. Each successive level is necessary for progressively smaller numbers of neonates.

Again most of these emergencies are Airway/Breathing problems.

This is a quote from the APLS manual to remind us of why this is important.