Advanced Life Support

Dr Rasnayaka M
Mudiyanse
MBBS.DCH.MD.MRCP

Use appropriate equipments

Use them as soon as they

are available

Oral and nasopharyngial

airways
Pharyngeal airways
Endotrachial tubes and
introducers
Laryngoscopes

ir way

Oxygen

Bag and Masks

reathing Ventilators
Pulse oxymeter
Fluid
Capnograph and blood gas
Adrenaline
Bicarbonate
analyzer

C
n

irculatio

IV Canular
Infusion pumps

Amiodoran
Antibiotics

Airways

Oropharangial airways

Indications GCS < 8 or AVPU < V

Size From tragus of the ear to incisor

Nasopharangial airways

Better tolerated
Contraindication Suspected fracture
base of the skullt
Size just fit in to the nostril

Newborn Life Support

Oropharyngeal Airways

RC (UK)

Resus 28

Newborn Life Support

RC (UK)

NLS Spec 4

Newborn Life Support

RC (UK)

NLS Spec 4

Masks for Oxygen Delivery

Deferent types available

Select the correct size
Make sure that there is no air leak
Transparent ones are better

Lesson 3: Self-inflating Bag:

Basic Parts

2000 AAP/AHA

Bag and Masks

Ensure a proper seal

Should achieve chest expansion or
recovery of the patient
Avoid gastric distension

Neck position
Cricoid pressure
Gastric tube

Avoid pneumothorax check blow off

valve

Jaw
thrust
RC (UK)

Resus 16

 RC (UK)

Resus 26

Intubation

NOT FOR IMMEDIATE

RESUSCITATION
Indications

For continuation of
ventilation
When you have a
experienced person and
failed air way

Selection of ET Tubes
ETT

Indication

Un
Cuffed

Pre pubertal Prevent

children
pressure
necrosis

Air leak

Cuffed

Post
pubertal
children

Pressure
necrosis

Can be used for pre

pubertal children

Advantag
es

Prevents
air
leakages

Dis
advantag
es

Size of the ET tube

Just fitting to the nostril no

blanching
Size of the small finger
Age ( yrs) /4 + 4
Neonates 2.5 kg 2.5 mm 3 kg 3
mm

Length of ET tube

Just up to the black mark

Oral airway - Age ( yrs)/4 + 12
Nasal airway Age(yrs)/4 + 15
Neonates 6.5 10 cm

Selection of Laryngoscope

Curved blade

Strait blade

Children and infants above neonatal

age
Neonates

Deferent sizes available

Figure 4.5 Intubation with curved blade

Figure 4.6 Intubation with a straight blade

laryngoscope lifting the epiglottis.

Pre requisites for

intubation

Equipments

ET Tubes appropriate size + One small and one large

Laryngoscope check whether it is functioning
Sucker
Bags and Ventilator

Competent person
Pre oxygenation
Resuscitate with bag and mask
Adequate sedation

Intubation

Visualize the vocal cords by displacing the

tongue to a side
Insert the tube through Vocal cords under
direct vision
Depth up to the black mark
Hold the tube until it is properly secured
Check whether it is in

Misting
Air entry
Recovery of child

Ventilating a child

Rate
FiO2
PIP
PEEP
I:E ratio

Laryngeal Mask Airway

Advantages of laryngeal
mask airway

Allows rapid access

Does not require laryngoscope
Relaxants not needed
Provides airway for spontaneous or
controlled ventilation
Tolerated at lighter anesthetic planes

Disadvantages of LMA

Does not fully protect against

aspiration in the non-fasted patient
Standard LMA does not allow high
positive pressure ventilation
Requires re-sterilization

Contra indications for LMA

Greater than 14 to 16 weeks pregnant

Patients with multiple or massive injury
Massive thoracic injury
Massive maxillofacial trauma
Patients at risk of aspiration
NOTE: Not all contraindications are
absolute

LMA size

Size 1:
Size 1.5:
Size 2:
Size 2.5
Size 3
Size 4
Size 5

Weight
under 5 kg
5 to 10 kg
10 to 20 kg
20 to 30 kg
30 kg to small adult
adult
Large adult/poor seal with size 4

Inflation volume
4 ml
7 ml
10 ml
14 ml
20 ml
30 ml
40 ml

Cricothyroidotomy
Only when every thing else failed

Fig 4.5 Surgical airway relevant anatomy

Pulse Oxymeter

Check the oxygen saturation

No indication about ventilation
Check pulse oxymeter reading
while in air to assess respiratory
distress

Fluid Boluses

For circulatory failure

20 ml/kg of crystalloid
Rpt 20 ml/kg of crystalloid
Rpt 20 ml/kg colloids

Dengue

10 ml/kg Rpt up to 5

Adrenaline indications and doses

Condition

Route

Dose

Cardiac arrest
Asystole, VF, PEA, VT

IV,IO,UV

10 micg/Kg

( 0.1 ml/kg of 1 in 10 000

solution)

IT

100 micg/Kg

( 0.1 ml/kg of 1 in 1

000

solution)

Anaphyl
axis

initial management

IM

solution)

not responding to IM IV infusion

adrenaline

0.1 0.3 micg/kg/min increase up to

1 micg/kg/min

IV infusion

For infusions 0.6 ml /kg of adrenaline 1 in 1000

is added to 100 ml of normal saline or 5%
dextrose and 1 ml/hour of above solution will
deliver 0.1 mcg/kg/min. (Nor- epinephrine also
reconstituted same way. The dose of nor
epinephrine is 0.1 2 micg/kg/min)

Brady cardia
not responding oxygenation

Circulatory
responding
ionotrophs

10 mic/Kg (0.01 ml/kg of 1 in 1000

to

failure
fluid

boluses

not IV infusions
and

Croup

Nebulization

5 ml of 1 in 1000 solution Can repeat

twice with a gap of 30 minute

Bronchiolitis

Nebulization

3 ml of 1 in 1000 solution two doses

30 minute apart

Bronchial asthma

SC/IM

0.01 ml/kg 0f 1 in 1000 solution

What to do? Critically ill

child

SAFE APPROACH
A
B
C
D

1. NO PALPABLE CENTRAL PULSE

CARDIAC ARREST
2. CENTRAL PULSE PALPABLE
CIRCULATORY FAILURE - SHOCK

Initial approach to Cardiac arrest

Stimulate and assess response
Open air Way
Check breathing
Five breaths

If You dont have

an ECG machine
Manage like
Asystole

Check pulse
Chest compression and ventilate
Shockable
VF/VT
algorithm

Assess rhythm

Non Shockable
Asystole
PEA

3 minutes

Cardiac Arrest
No palpable central pulse. Possible causes are ?

Asystole

Ventricular fibrillation VF

Pulse less ventricular tachycardia VT

Pulse less electrical activity (Electro

mechanical dissociation) EMD

Basic
Electrocardiography

P wave = atrial depolarisation

QRS = ventricular depolarisation

(< 0.12 s)

T wave = ventricular
repolarisation

Asystole

CARDIAC ARREST - ASYSTOLE

Adrenaline

Fluid bolus

1st 10mcg /kg IV/IO -0.1ml/kg of 1:10,000 solution

2nd 10 mcg / kg, IV / IO -0.1-1 ml/kg of 1:10,000 solution

IV Fluid 20 ml/kg Normal saline, may need a second

bolus.

CPR for 3 minutes

Rpt Adrenaline every 3-5 mt. (every
other loop)

Pulseless Electrical Activity

Pulse less electrical

activity

Fluid boluses
Adrenaline
Treat the causes H4T4

Hypothermia , Hypoxia, Hypoglycaemia,

Hyponatriemia
Tension pneumothorax, Thromboembolism, Temponade,
Taruma

Ventricular Fibrillation

Ventricular Tachycardia

CARDIAC ARREST VF or Pulseless VT

Basic methods ABC Oxygen, CPR

1st Shock (4J/kg) ( Australian guidelines 2 j/kg)

Consider H4T4 CPR 2 mt. Intubate
2nd Shock (4j/kg) CPR 2 mt
Adrenaline 10 micg / kg, IV/IO 3rd Shock
( 4j/kg) CPR 2 mt
Amiodorane 5 mg/kg 4th Shock CPR
Adrenaline 10 micg / kg, IV/IO 5rd Shock
( 4j/kg) CPR 2 mt ( Rpt every other cycle)
Fluid bolus 20 ml/kg

Placing electrode paddles

Size 8-12 cm for child and 4.5 cm

for infants
R just below the clavicle
L Anterior axillary line
Dose 4 j/kg
AED attenuated for children

Adult AED can be used for children

Infants has not been studied

What to do? Critically ill

child

SAFE APPROACH
A
B
C
D

1. NO PALPABLE CENTRAL PULSE

CARDIAC ARREST
2. CENTRAL PULSE PALPABLE
CIRCULATORY FAILURE - SHOCK

Palpable Pulse present

BUT poor circulation - Shock

If HR less than 60/mt commence CPR with

ECM
If HR more than 60/mt

Oxygen
Fluid bolus
Inotropes , Adrenaline, Dopamine, Dobutamine
Treat the cause

Consider sepsis Cefotaxime +/- Fluclox or

Vancomycin
Hypoglycaemia 3 -5 ml/kg of 10% dextrose

Thank you