344 Paediatric Emergencies
CARDIOPULMONARY RESUSCITATION(ii) Change to a ventilation rate of 10–12/min and compression rate
of 100/min without interruption, once the airway is protected
with an endotracheal tube
(a) use a ventilation rate of 12–20/min once the circulation is
restored to achieve a normal PaCO 2.
5 Vascular access
(i) Vascular access will be difficult, but is needed to administer drugs
and fluids and obtain blood samples. Consider intraosseous (i.o.)
access early in the resuscitation, and call for equipment.
(ii) Venous access
(a) insert a 20- or 22-gauge cannula into a familiar site such as
the antecubital fossa, the back of the hand, external jugular or
internal jugular vein
(b) perform i.o. (bone marrow) vascular access, if venous access
is not gained within 60 s or is likely to take longer than this.
(iii) Intraosseous access (see p. 480).
(a) i.o. access is rapid, safe and effective for administering drugs,
fluids and blood products, and for drawing blood for cross-
match, blood sugar and chemical analysis
(b) use in children when i.v. access has failed or will take over
60 s to perform
(c) insert the i.o. needle into the anteromedial surface of the
proximal tibia, 1–2 cm distal to the tuberosity. Advance the
needle with a gentle twisting or boring motion until it gives on
entering the marrow cavity, and remove the stylet (see p. 480)
(d) alternatively, use a semi-automatic, hand-held i.o. drill device
(e) aspirate blood and marrow contents to confirm correct
placement
(f) flush each drug with a bolus of normal saline to ensure
dispersal beyond the marrow cavity and to achieve faster
central circulation distribution.
(iv) Connect an infusion of normal saline via a paediatric giving set
slowed to a minimal rate to the vascular or venous access
(a) give an initial fluid bolus of 20 mL/kg rapidly if systemic
perfusion is inadequate.
(v) Intratracheal adrenaline (epinephrine), atropine and lignocaine
(lidocaine) are no longer recommended, as absorption is highly
variable, and i.v. or i.o. access are definitely preferred. If the
intratracheal route is ever used:
(a) adrenaline (epinephrine) endotracheal dose is 100 g/kg (10
times the recommended i.v. dose)
(b) dilute in 5 mL normal saline and follow with five ventilations.
6 Drug administration
(i) Recommended drug doses are shown in Table 11.4.