Chapter 36: Emergency Care – ABC, Cardiac Arrest & Resuscitation

Initial assessment · Airway · Breathing · Circulation · Cardiac arrest rhythms · Asystole · PEA · VF · Stopping resuscitation · Post‑resuscitation care
⚡ Key principles: Systematic ABCDE approach. High‑quality CPR (depth, rate, recoil). Shockable rhythms (VF/pVT) → defibrillation. Non‑shockable (asystole/PEA) → epinephrine, treat H’s & T’s. Termination of resuscitation guided by duration, etiology, response.

🚨 Summary: ED management of the critically ill/injured child

🩺 Initial assessment (ABCDE)
Airway (patency, C‑spine), Breathing (rate, effort, SpO2), Circulation (pulses, CRT, BP), Disability (GCS, pupils), Exposure (temperature, rash, trauma).
🫁 Airway & Breathing
Open airway (jaw thrust). Suction. O2, bag‑mask ventilation, advanced airway if apneic. Tension pneumothorax decompression.
💓 Circulation & Cardiac arrest rhythms
IV/IO access, fluid bolus for shock. Cardiac arrest: asystole, PEA, VF/pVT. High‑quality CPR (100-120/min, depth 1/3 AP diameter).
⚡ Asystole / PEA management
CPR, epinephrine (0.01 mg/kg IV/IO q3‑5 min), treat reversible causes (H’s & T’s: hypoxia, hypovolemia, hyper/hypokalemia, tension pneumothorax, tamponade, toxins, thrombosis).
🔄 Ventricular fibrillation (VF)
Defibrillate 2 J/kg → 4 J/kg, resume CPR immediately. Epinephrine after 2nd shock, amiodarone for refractory VF.
🛑 Stopping resuscitation
No ROSC after 20-30 min of high‑quality CPR without reversible cause; family discussion; consider organ donation.
📊 Key reversible causes (H’s & T’s): Hypoxia, Hypovolemia, Hydrogen ion (acidosis), Hyper/hypokalemia, Hypothermia; Tension pneumothorax, Tamponade (cardiac), Toxins, Thrombosis (pulmonary/coronary).

🔍 Approach to the severely ill/injured child – ED systematic assessment

1
Primary survey (ABCDE) – Immediate life‑threats: airway obstruction, apnea, tension pneumothorax, massive hemorrhage. Intervene as found.
2
Airway + C‑spine – Look, listen, feel. If obstructed: chin lift/jaw thrust (avoid neck extension in trauma). Suction, oral/nasal airway, prepare for intubation.
3
Breathing – Respiratory rate, oxygen saturation, use of accessory muscles, breath sounds. Give high‑flow O2, bag‑valve‑mask if inadequate, decompress tension pneumothorax.
4
Circulation – Heart rate, pulses (central vs peripheral), capillary refill, blood pressure. Gain IV/IO access, 20 mL/kg fluid if shock present. Identify cardiac arrest rhythms.
5
Disability & Exposure – AVPU/GCS, pupillary response. Log roll, inspect for injuries, temperature management.

📋 Stepwise management: cardiac arrest & post‑resuscitation

1
Immediate CPR & defibrillation (if shockable rhythm) – Start high‑quality CPR (15:2 for 2 rescuers, 30:2 alone). Attach AED/defibrillator. For VF/pVT: 2 J/kg → 4 J/kg.
2
Epinephrine for non-shockable rhythms – Asystole or PEA: epinephrine 0.01 mg/kg (0.1 mL/kg of 1:10,000) IV/IO, repeat q3‑5 min. Identify and treat H’s/T’s.
3
Advanced airway & capnography – After intubation, continuous waveform capnography to confirm tube placement and monitor CPR quality. Ventilate 1 breath q6s (10/min).
4
Refractory VF/pVT – Amiodarone 5 mg/kg IV/IO (or lidocaine), repeat defibrillation. Consider magnesium for torsades.
5
Reversible causes (H’s & T’s) – Hypovolemia (fluids, blood), hypoxia (oxygen, ventilation), tension pneumothorax (needle decompression), cardiac tamponade (pericardiocentesis), toxins (naloxone, etc.), thrombosis (thrombolytics/embolectomy).
6
Decision to stop resuscitation – No ROSC despite >20-30 min of high‑quality CPR, no reversible cause, no response to defibrillation/epinephrine. Discuss with team and family; document.
⚡ Critical actions: Minimize chest compression interruptions (<10 sec). Rotate compressor q2min. Use end‑tidal CO₂ >20 mmHg as marker of good CPR. After ROSC, target normothermia, avoid hyperoxia, support blood pressure.

🧠 Rapid reflex prompts – ABC & cardiac arrest

🫁 First action in unresponsive child?
Assess airway and breathing; open airway (jaw thrust).
💓 First dose of epinephrine in cardiac arrest
0.01 mg/kg (1:10,000) IV/IO. Repeat q3‑5 min.
⚡ Energy for first defibrillation in child?
2 J/kg; second shock 4 J/kg.
🩸 Most common reversible cause of PEA in trauma?
Hypovolemia (hemorrhage) – fluids, blood, control bleeding.
🛑 When to consider terminating resuscitation?
No ROSC after 20-30 min of high‑quality CPR without reversible cause; prolonged unwitnessed arrest with asystole.
🫀 Characteristics of high‑quality CPR
Depth: 1/3 AP diameter (approx. 4 cm infant, 5 cm child); rate 100-120/min; full chest recoil; minimize pauses.