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At the onset of ventricular fibrillation (VF), the QRS complexes are regular, widened, and of
tall amplitude, suggesting a more organized ventricular tachyarrhythmia. Over a brief
period of time, the rhythm becomes more disorganized with high amplitude fibrillatory
waves; this is coarse VF. After a longer period of time, the fibrillatory waves become fine,
culminating in asystole.
Vascular access
Peripheral proximal upper extremity is the
location of choice for IV administration
IO vascular access in the proximal tibia or distal
femur should be initiated if peripheral access
cannot be achieved in 3 attempts or 90 seconds
in a child younger than 6 years of age
IO access is a rapid, safe, and effective route for
the administration of medications and fluids
Central venous access (preferably femoral)
should be obtained, if IO access is unsuccessful
or if the child is over six years of age
Intraosseous (IO) access
Easily to achieved
Recommended in cardiac arrest if no IV
access in place or fail to achieve quickly
Commonly used at distal femur, proximal
tibia, and distal tibia (medial malleolus)
Proximal tibia is the most common
Often successful and relatively free
complications
Potential problems : failure to place the
needle, fracture, infection, and compartment
syndrome (extravasation of fluid)
Fluids
Use isotonic crystalloid solution (eg,
lactated Ringers solution, normal saline)
or colloid (eg, albumin)
Fluid boluses, 20 mL per kg rapidly until
the shock is resolved (delivered in less
than 20 minutes)
Use a glucose-containing solution to only
treat documented hypoglycemia
Algorithm of hemodynamic support
in infants and children (1)
0
Recognize decreased mental status and perfusion. Begin high flow
O2. Establish IV/IO access.
5
Initial resuscitation:
If 2nd PIV
Push boluses of 20 cc/kg isotonic saline or colloid up to & over 60 start
cc/kg until perfusion improves or unless rales or hepatomegaly inotrope.
develop. Correct hypoglycemia & hypocalcemia. Begin antibiotics.
Shock not reserved?
15
dose range:
Fluid refractory shock: dopamine up
Begin inotrope IV/IO. Use atropin/ketamine IV/IO/IM to obtain to 10 mcg/
central access & airway if needed. Reserve cold shock by titrating kg/min,
epinephrine
central dopamine or, if resistent, titrate central epinephrine.
0.05 to 0.3
Reserve warm shock by titrating central norepinephrine. mcg/kg/min
60
min Catecholamine resistant shock:
Begin hydrocortisone if at risk for absolute
adrenal insufficiency
Inotropes/Vasoactive Agents
DRUGS DOSAGES
Dopamine 1-5 mcg/kg/min: dopaminergic; 5-15 mcg/kg/ min:
more beta-1; 10-20 mcg/kg/min: more alpha-1
Dobutamine 2.5-15 mcg/kg/min; mostly beta-1, some beta-2