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So, if all else fails and the child is left in respiratory distress, that will bring us to this next subject, which is respiratory arrest completely. And respiratory arrest, remember, is when the patient has a pulse but no respirations. Remember advanced life support starts with excellent BLS. And if you believe your patient is unresponsive, then start by tapping and shouting to verify. If your patient is unresponsive, call for advanced care and assistance. In a hospital setting this might include calling a medical code. Make sure to follow your local protocol. And make sure that the certain ways that your team have practiced the code are followed. Obviously, these Emergency Response Team codes are being worked on so that we have the most efficient team efforts in completing good resuscitative care. And in the pediatric patient, so that we don't allow respiratory arrest to quickly go into the ultimate arrest, cardiac arrest. In a pre-hospital setting this may include getting assistance from another Advanced Life Support. We call those ALS units. Maybe it's a higher level of transportation, especially in certain communities where they use a basic life support ambulance that's intercepted with advanced life support. Next we're going to assess circulation and breathing by checking for a pulse. If it's on a child it's going to be a carotid pulse. If it's on an infant, it's the brachial pulse. We want to look at the face and chest at this time for signs of breathing. For a patient in respiratory arrest we would find there is a pulse but there is no adequate breathing. Remember the agonal respirations or snoring respirations do not qualify as effective breathing. So now that we've decided to give rescue breathing we should open the airway with a head-tilt chin lift. A folded towel or maybe even a diaper placed under the infant's shoulders could help with the correct positioning in order to keep the airway open, yet not hyper extend the neck. Placing a basic airway can help keep the tongue out of the back of the throat and help ensure ventilations are successful. An oropharyngeal airway, or OPA for short, would be measured by placing it alongside the patient's face from the corner of the mouth to the lower tip of the ear. If the OPA is longer than this area or too big, it could actually cause a blockage and defeat the purpose. In addition, we will always check to see if there's a gag reflex before attempting to place an OPA. If there is a gag reflex, don't attempt an OPA as this can cause vomiting which may just complicate the airway management and oxygenation. Now at this point we need to deliver one breath every three seconds for a child or an infant. This would be about 20 breaths per minute. Breaths should be given with a bag valve mask at 15 liters per minute of oxygen. After rescue breathing has begun, a heart monitor should be attached and vitals assessed with oxygen saturation, the blood pressure, and a pulse. As breaths are being delivered it's important to monitor their effectiveness. This can be done by watching for a good chest rise and fall and if the patient is intubated, monitoring capnography and avoiding gastric inflation will be achievable. This is why our next action should be placing an advanced airway and gaining IV or IO access. Remember, if the pulse rate drops below 60 beats per minute, start compressions. Also let's remember to look for and treat underlying causes of the respiratory arrest all along the path to successful resuscitation.
If a pediatric patient is left in a state of respiratory distress too long, after a while, that will lead to the subject of this lesson – complete respiratory arrest.
Remember, a patient in respiratory arrest has a pulse but no respirations. Advanced life support begins with excellent basic life support skills. So, if you believe the patient to be unresponsive, verify that by tapping on the child's collarbone and shouting.
If you still do not get a response, call for advanced level care and assistance, as this will be your first step in resolving the respiratory arrest.
In a hospital setting, call in a medical code and follow your appropriate local respiratory and/or cardiac arrest protocol. In pediatric patients, it's important to not let their respiratory arrest deteriorate into a more significant arrest – cardiac arrest.
Pro Tip #1: Practice makes perfect, especially in an emergency situation. So, make sure you're following and carrying out the code in the same ways you've practiced, which will lead to a more efficient and effective emergency response team effort and the delivery of good resuscitation team care.
In a pre-hospital setting, get assistance as needed from another advanced life support unit, which may include a higher level of transportation. This will be relevant in certain communities that use a basic life support ambulance that is then intercepted by another advanced life support vehicle and team.
The next thing you'll want to do is assess the patient for circulation and breathing, including checking for a pulse. On a child, check the carotid pulse. On an infant, check the brachial pulse. And look at the patient's face and chest, while checking for a pulse, for any signs of breathing.
Pro Tip #2: Remember, for a patient in respiratory arrest, you'll find a pulse but no adequate breathing. Also worth mentioning again – agonal respirations (or snoring respirations) do not qualify as normal and effective breathing and should be considered the same as no adequate breathing.
At this point, you will have decided to begin to provide rescue breathing, but first open the airway with a proper head-tilt, chin lift. If you have a folded towel, blanket, or diaper available, placing it under the patient's shoulders may help achieve the proper positioning, which will help keep the airway open.
Make sure, though, not to hyperextend the patient's neck, as this will produce the opposite effect – closing the airway, rather than keeping it open.
Placing a basic airway can help keep the tongue out of the back of the throat and ensure more successful ventilations. Get an oropharyngeal airway (OPA) measurement by placing it along side the patient's face, from the corner of the mouth to the lower tip of the ear.
Warning: Getting a proper measurement is important. If the OPA is longer than that area or too wide for the patient, this could cause a blockage of the airway and defeat the purpose.
Pro Tip #3: Remember to check for a gag reflex before you attempt to place an OPA into the patient's airway. If there is a gag reflex, do not attempt an OPA, as this can cause the patient to vomit, which could seriously complicate airway management and oxygenation.
Deliver 1 rescue breath every 3 seconds for a child or infant, which is about 20 breaths per minute. Breaths should be given with a bag valve mask at 15 liters per minute of oxygen.
After you've begun to deliver rescue breathing, attach a heart rate monitor and assess the patient's vitals:
As rescue breaths are delivered, it's important to monitor their effectiveness by watching the patient's chest. Do you see it rise and fall? And if the patient is intubated, monitor capnography and avoid gastric inflation.
The next step is to place an advanced airway and gain IV or IO access. And remember, if the patient's pulse rate drops below 60 beats per minute, start chest compressions immediately.
Pro Tip #4: Also, as part of your resuscitation protocol and care, keep in mind that you'll want to look for, and treat, any underlying causes of the patient's respiratory arrest.