C1

9 YR OLD BOY -SNOW BOUND GOLF COURSE - AXDENT

CRA- VF- hypoTHERMIA- fracture Rt tib fib

9 YR 3/7 34KG

A- EAP-ET

B-BMO2 BTO2

C-IV/IO VF PROTOCOL

G-UIBLS RESUS UNTIL  TEMP OVER 32C 

S- ACTIVE REWARMING 

VF PROTOCOL ---- DC2....MDC2.....MDAAMC2......MDC2.....MDAAMC2....4H VOTK  4T TATETOTH 

M-RC PC SOL 

PEAAS- AC2....RC2....ARC2.....RC2

Shockable (VF/pVT)

This is less common in children but may occur as a secondary event and is likely when there has been a witnessed and sudden collapse. It is seen more often in the intensive care unit and cardiac ward.

• Continue CPR until a defibrillator is available – as 5A above
• Defibrillate the heart:
  • Charge the defibrillator while another rescuer continues chest compressions.
  • Once the defibrillator is charged, pause the chest compressions, quickly ensure that all rescuers are clear of the patient and then deliver the shock. This should be planned before stopping compressions.
  • Give 1 shock of 4 J kg-1 if using a manual defibrillator.
  • If using an AED for a child of less than 8 years, deliver a paediatric-attenuated adult shock energy.
  • If using an AED for a child over 8 years, use the adult shock energy.
• Resume CPR:
  • Without reassessing the rhythm or feeling for a pulse, resume CPR immediately, starting with chest compression.
  • Consider and correct reversible causes (4Hs and 4Ts).
• Continue CPR for 2 min, then pause briefly to check the monitor:
  • If still VF/pVT, give a second shock (with same energy level and strategy for delivery as the first shock).
• Resume CPR:
  • Without reassessing the rhythm or feeling for a pulse, resume CPR immediately, starting with chest compression.
• Continue CPR for 2 min, then pause briefly to check the monitor:
• If still VF/pVT, give a third shock (with same energy level and strategy for delivery as the previous shock).
• Resume CPR:
  • Without reassessing the rhythm or feeling for a pulse, resume CPR immediately, starting with chest compression.
  • Give adrenaline 10 mcg kg-1 and amiodarone 5 mg kg-1 after the third shock, once chest compressions have resumed.
  • Repeat adrenaline every alternate cycle (i.e. every 3–5 min) until ROSC.
  • Repeat amiodarone 5 mg kg-1 one further time, after the fifth shock if still in a shockable rhythm.
• Continue giving shocks every 2 min, continuing compressions during charging of the defibrillator and minimising the breaks in chest compression as much as possible.
  • After each 2 min of uninterrupted CPR, pause briefly to assess the rhythm: If still VF/pVT:
    
    • Continue CPR with the shockable (VF/pVT) sequence.
  • If asystole:
    
    • Continue CPR and switch to the non-shockable (asystole or PEA) sequence as above.
  • If organised electrical activity is seen, check for signs of life and a pulse:
    
    • If there is ROSC, continue post-resuscitation care.
    • If there is no pulse (or a pulse rate of <60 min-1), and there are no other signs of life, continue CPR and continue as for the non-shockable sequence above.

If defibrillation was successful but VF/pVT recurs, resume the CPR sequence and defibrillate. Give an amiodarone bolus (unless two doses have already been given) and start a continuous infusion of the drug.

Important note 
Uninterrupted, high quality CPR is vital. Chest compression and ventilation should be interrupted only for defibrillation. Chest compression is tiring for providers and the team leader should repeatedly assess and feedback on the quality of the compressions. To prevent fatigue, change providers should every two minutes. This will mean that the team can deliver effective high quality CPR so improving the chances of survival.2,14

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 Non-shockable (asystole or PEA):

This is the more common finding in children.

• Perform continuous CPR:
  • Continue to ventilate with high-concentration oxygen.
  • If ventilating with bag-mask give 15 chest compressions to 2 ventilations.
  • Use a compression rate of 100–120 min-1.
  • If the patient is intubated, chest compressions can be continuous as long as this does not interfere with satisfactory ventilation.
  • Once the child's trachea has been intubated and compressions are uninterrupted use a ventilation rate of approximately 10–12 min-1. Note: Once there is return of spontaneous circulation (ROSC), the ventilation rate should be 12–20 min-1. Measure end-tidal carbon dioxide (CO2) to monitor ventilation and ensure correct tracheal tube placement.
• Give adrenaline:
  • If vascular access has been established, give adrenaline 10 mcg kg-1 (0.1 mL kg-1 of 1 in 10,000 solution).
  • If there is no circulatory access, obtain intraosseous (IO) access.
• Continue CPR, only pausing briefly every 2 min to check for rhythm change.
  • Give adrenaline 10 mcg kg-1 every 3–5 min (i.e. every other loop), while continuing to maintain effective chest compression and ventilation without interruption.
• Consider and correct reversible causes (4Hs and 4Ts):
  • Hypoxia
  • Hypovolaemia
  • Hyper/hypokalaemia, metabolic
  • Hypothermia 
  • Thromboembolism (coronary or pulmonary)
  • Tension pneumothorax
  • Tamponade (cardiac)
  • Toxic/therapeutic disturbance