PALS Course Outline 2011 Olton/Plainview EMT-P Courses

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1 PALS Course Outline 2011 Olton/Plainview EMT-P Courses I. PALS Course Overview/Registration II. III. IV. PALS Science Overview Video Child/Infant CPR/AED Review Video Management of Respiratory Emergencies Video V. Review of Respiratory Emergencies Flow Charts Recognition of Respiratory Problems Flow Chart Management of Respiratory Emergencies Flow Chart VI. VII. Review of Rhythm Disturbances/Electrical Therapy Procedures Handouts Vascular Access Video VIII. Resuscitation Team Concept Video IX. Overview of Pediatric Assessment Video X. Review of Pediatric Assessment XI. XII. Review of Shock Handouts Recognition of Shock Flow Chart Management of Shock Flow Chart Review of PALS Cardiac Arrest Priorities CPR Defibrillation IV Access/Medications Advanced Airway Management XIII. Review of Rhythm Treatment Priorities Rate Rhythm Blood Pressure XIV. Review of Cardiac Treatment s AHA Pulseless Arrest SPEMS s a. VF/Pulseless V-Tach (Pediatric) b. Asystole/PEA (Pediatric) AHA Bradycardia SPEMS Pediatric Bradycardia AHA Tachycardia SPEMS s a. SVTs b. V-Tach with a Pulse XV. Putting it all Together Core Case Studies a. Respiratory Cases 1, 2, 3, 4 b. Cardiac Cases 3, 4 c. Shock Cases 1, 2, 3, 4 Pediatric Megacodes (Class) XVI. Written Exam 25 Questions Minimum Passing Grade: 84% XVII. Retesting (As Needed) 1

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4 American Heart Association Learn and Live Rhythm Disturbances! Electrical Therapy Procedures 2006 American Heart Association 4

5 Procedure for Cardiac Monitoring Introduction Management of any seriously ill or injured patient requires assessment of heart rate and rhythm (cardiac monitoring). Procedure Follow these steps to perform cardiac monitoring. Modify for your specific device. Step Action 1 Power on monitor/defibrillator. 2 Attach ECG leads to patient: White lead-to right shoulder Red lead-to left flank or abdomen Ground (black, green, brown) lead-to left shoulder Note: In units with cardiovascular patients, 5-lead monitoring may be used. For 5-lead monitoring the green lead is placed under the white, lower on the torso. The brown lead is placed in the middle of the chest. Placement of electrodes for ECG monitorin. 3 Adjust device to manual ECG monitoring mode (not AED mode or paddles) to display rhythm in standard limb leads I, II, III. 4 Visually check monitor screen and assess heart rate and rhythm American Heart Association 2 5

6 Emergency Interventions for Tachyarrhythmias Introduction Specific emergency interventions for tachyarrhythmias include vagal maneuvers synchronized cardioversion Vagal Maneuvers Vagal Maneuvers In normal infants and children the heart rate falls with stimulation of the vagus nerve. In patients with supraventricular tachycardia (SVT), vagal stimulation may terminate the tachycardia. Several maneuvers stimulate vagal activity. The success rates of these maneuvers in terminating tachyarrhythmias vary, depending on the child's age, level of cooperation, and underlyill9 condition. If possible, obtain a 12-lead EGG before and after the maneuver; record and monitor the EGG continuously during the maneuver. If the patient is stable and the rhythm does not convert, you may repeat the attempt. If the second attempt fails, select another method or provide pharmacologic therapy. If the patient is unstable, attempt vagal maneuvers only while making preparations for pharmacologic or electrical cardioversion. Do not delay definitive treatment with vagal maneuvers. Maneuver Application of ice to the face Description This is the most effective vagal maneuver in infants and young children. Method One method is to mix crushed ice with water in a plastic bag or glove (Figure 1). While recording the EGG, apply the ice water mixture to the infant's face for only 10 to 15 seconds. Do not obstruct ventilation (ie, cover only the forehead, the eyes, and the bridge of the nose). If this method is successful, SVT will terminate in seconds. ( 2006 American Heart Association 3 6

7 Val salva maneuver Figure 1. Ice water is applied to the infant's face for vagal stimulation in an attempt to terminate SVT. Note that the bag of ice water does not cover the nares or mouth and does not obstruct ventilation. Other vagal maneuvers may be effective and appear to be safe, based on data obtained largely in older children, adolescents, and adults. Older children can be taught to use these maneuvers on their own. Method I nstruct the child to blow through an obstructed straw blow on his thumb as if it were a trumpet without letting any air out while blowing, bear down as if passing a bowel movement hold his breath while ice is laced to the face Do not use the following methods to induce vagal activity: Application of external ocular pressure Carotid massage 2006 American Heart Association 4 7

8 ( \ Synchronized Cardioversion Introduction Synchronized cardioversion is used for children with tachyarrhythmias (SVT, ventricular tachycardia [VT] with pulses, atrial flutter, atrial fibrillation) that are unstable (ie, associated with evidence of cardiovascular compromise, such as poor perfusion, hypotension, or heart failure) requiring immediate cardioversion by an appropriately skilled provider stable-permitting elective cardioversion at the direction of a pediatric cardiologist During synchronized cardioversion electrical therapy is administered through adhesive electrode pads or handheld paddles. You will need to place the defibrillator/monitor in synchronized (sync) mode. The sync mode is designed to deliver energy just after the R wave of the QRS complex. Technique Follow these steps to perform synchronized cardioversion. Modify for your specific device. ( Step Action 1 Consider sedation but do not delay cardioversion in an unstable patient. 2 Power on the monitor/defibrillator (monophasic or biphasic). i 3 Attach monitor leads to the child ("white to right, red to I ribs, what's left over to the left shoulder") and ensure proper display of the child's rhythm. 4 Interpret the heart rhythm. Confirm indication for I synchronized cardioversion. 5 Press the SYNC control button to engage synchronization mode. 6 Look for markers on the R wave indicating sync mode. Adjust monitor gain if necessary until sync markers occur I with each R wave. 7 Select the appropriate energy level. The initial energy dose for synchronized cardioversion is 0.5 to 1 J/kg. If tachyarrhythmia persists after the first attempt, double the dose to 1 to 2 J/kg. 8 Select the largest paddles or pads that will fit on the chest wall without touching. Prepare paddles and J 2006 American Heart Association 5 8

9 i conducting surface for placement. Place paddles/pads correctly. (See steps 2, 3, and 4 in the Procedure for Manual Defibrillation on the student CD.) 9 Announce to team members: "Charging cardioverterstand clear!" 10 Press the CHARGE button. 11 When the cardioverter is fully charged, clear the patient. To ensure the safety of cardioversion, always announce when you are about to deliver a shock (eg, "I am going to shock on three. One, I'm clear. Two, you're clear, oxygen's clear. Three, everybody's clear." Direct oxygen flow away from the patient's chest and consider temporarily disconnecting the bag or the ventilation circuit from the endotracheal tube during shock delivery. 12 Press the DISCHARGE buttons simultaneously on the paddles or the SHOCK button on the cardioverter. 13 Check the monitor to evaluate the rhythm. If the tachyarrhythmia persists, increase the energy level Goules) according to the appropriate algorithm. 14 Activate the sync mode after delivery of each synchronized shock if the patient remains in a tachycardic rhythm. Most defibrillators default back to the unsynchronized mode after delivery of a synchronized shock. This default allows an immediate shock if cardioversion produces VF American Heart Association 6 9

10 Procedure for Manual Defibrillation Introduction Defibrillation shocks are indicated for ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT). To treat VF/pulseless VT effectively, you need to know how to operate a manual defibrillator and perform manual defibrillation. Procedure Follow these steps to operate a manual monitor/defibrillator (either biphasic or monophasic) and attempt manual defibrillation. Modify for your specific device. Step Action 1 Power on monitor/defibrillator. 2 Select the proper pads or paddles. Attach adhesive electrode pads. Select largest paddles or pads that will fit on the chest wall without touching. i Weight/Age Paddle/Pad Size 10 kg Large adult paddles (8 to 13 cm) ( approximately 1 Adult pads year old) <10 kg Small infant paddles (4.5 cm) «1 year old) Pediatric pads 3 Prepare paddles/pads for rhythm identification and shock delivery. If using paddles, apply electrode cream or paste to them. Placing paddles directly on the child's bare skin decreases the delivered current. Note: Do not use saline-soaked gauze pads or sonographic gels. Do not use alcohol pads because they may pose a fire hazard and produce chest burns. If using adhesive electrode pads, peel the backing away. 4 Position paddles or pads so that the heart is between them. Place one paddle or pad on the upper right side of the chest below the clavicle, along the patient's right upper sternal border. Place the other paddle/pad lateral to the left nipple in the anterior axillary line (positioned under and to the left of the nipple and between the nipple and the axilla). Make sure paddles do not touch. Do not overlap pads American Heart Association 7 10

11 \ An alternative method is to place the paddles/pads in an anterior-posterior position with one just to the left of the sternum and the other over the back. Anterior-posterior placement may be necessary if the child is an infant and only large paddles or pads are available. In dextrocardia, position pads in a mirror image of the standard placement. Adjust device to manual mode (not AED mode). If necessary, adjust LEAD button to display rhythm in standard limb leads I, II, or III (if EGG leads are used) paddles (if paddles are used instead of pads) Interpret heart rhythm. Confirm indication for defibrillation. Adjust ENERGY button to select appropriate energy dose. An initial dose of 2 J/kg (biphasic or monophasic waveform) is recommended. If this dose does not terminate VF or pulseless VT, deliver subsequent doses of 4 J/kg. Apply firm pressure to paddles to create good contact between the paddle and the skin. Ensure good contact between the skin and the adhesive electrode pad. If a large amount of hair on the chest prevents good skin-electrode contact, quickly shave the area and reapply the paddle/pad. Modifications may be required in special situations. i Special Situation Standing water Implanted defibrillator or pacemaker Transdermal medication patch Modification Remove the victim 'from the water and quickly wipe the chest. Do not place an electrode pad directly over the implanted device because the device may reduce delivery of current to the heart. Place the pad at least 1 inch (2.5 cm) to the side of the implanted device. Do not place an electrode pad directly over a medication patch. If the patch is in the way, remove it and wipe the child's skin before attaching the pad. 10 Press the CHARGE button to charge the defibrillator. The CHARGE button is located either on the defibrillator or 2006 American Heart Association 8 11

12 on one or both paddles. If the device requires more that 10 seconds to charge, rescuers may resume chest compression until the device is charged and ready for shock delivery. 11 "Clear" the patient when the defibrillator is fully charged. To ensure the safety of defibrillation, always announce when you are about to deliver a shock. State a "warning" firmly and in a forceful voice before delivering each shock (this entire sequence should take less than 5 seconds). You may use a warning like this: "I am going to shock on three. One, I'm clear." Check to make sure you are clear of contact with the patient, the stretcher, or other equipment. "Two, you're clear." Make a visual check to ensure that no one is touching the patient or stretcher. In particular, check the person providing ventilations. That person's hands should not be touching the ventilatory adjuncts, including an advanced airway. Be sure oxygen is not flowing across the patient's chest. Direct flow away from the patient's chest and consider temporarily disconnecting the bag or the ventilation circuit from the endotracheal tube during shock delivery. "Three, everybody is clear." Check yourself one more time before pressing the SHOCK button(s). You need not use these exact words, but you must warn others that you are about to deliver shocks and that everyone must stand clear. 12 Press SHOCK button(s) to deliver current. Press either a Single SHOCK button located on the defibrillator both SHOCK buttons on paddles simultaneously 13 Immediately resume CPR starting with chest compressions for about 2 minutes American Heart Association 9 12

13 Pediatric Assessment Flowchart American Heart ~ Association ~ Learn and Live '" General Assessment Appearance... Work of Breathing'" Circulation O Primary Assessment Airway Breathing Circulation Disability Exposure Secondary Assessment (SAMPLE history, focused physical exam, bedside glucose) Tertiary Assessment (laboratory studies, x-rays, other tests) Categorize illness by type and severity Respiratory Circulatory Respiratory distress or Respiratory failure Upper airway obstruction Lower airway obstruction Lung tissue disease Disordered control of breathing Compensated shock or Hypotensive shock Hypovolemic shock Distributive shock Cardiogenic shock Obstructive shock Respiratory + Circulatory including cardiopulmonary failure If at any time during the assessment and categorization process you identify a life-threatening condition Immediately initiate life-saving interventions and activate the emergency response system 2006 American Heart Association 13

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15 PALS Management of Shock Emergencies Flowchart American Heart ~ Associatioll ~ Learn and Live SM Management of Shock Emergencies Flowchart Nonhemorrhagic 20 mukg NS/LR bolus, repeat as needed Consider colloid after 3rd NS/LR bolus Management : Septic Shock Oxygen Pulse oximetry ECG monitor IV/IO access BLS as indicated Bedside glucose Hypovolemic Shock Specific Management for Selected Conditions Hemorrhagic Control external bleeding 20 mukg NS/LR bolus repeat 2 or 3x as needed Transfuse PRBCs as indicated Distributive Shock Specific Management for Selected Conditions Septic Anaphylactic Neurogenic 1M epinephrine (or auto-injector) Antihistamines Corticosteroids Epinephrine infusion Albuterol BradyarrhythmialTachyarrhythmia Management s: Bradycardia Tachycardia with poor perfusion Cardiogenic Shock Specific Management for Selected Conditions 20 mukg NS/LR bolus, repeat PRN Vasopressor Other (eg, CHD, Myocarditis, Cardiomyopathy, Poisoning) 5 to 10 mukg NS/LR bolus, repeat PRN Vasoactive infusion Consider expert consultation Obstructive Shock Specific Management for Selected Conditions Ductal-Dependent (LV Outflow Obstruction) Tension Pneumothorax Cardiac Tamponade Pulmonary Embolism Prostaglandin E, Expert consultation Needle decom pression Tube thoracostomy Pericardiocentesis 20 mukg NS/LR bolus 20 mukg NS/LR bolus, repeat PRN Consider thrombolytics, anticoagulants Expert consultation 2006 American Heart Association 15

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17 VENTRICULAR FIBRILLATION, or PULSELESS VENTRICULAR TACHYCARDIA* - PEDIATRIC EMT- Paramedic 1. ABCs 2. CPR (2005 Guidelines)** 3. Ventilate with Oxygen (Insert OPA/NPA) 4. Use ResQPOD if the patient has reached puberty 5. Attach Defibrillator 6. 2 Joules/kg or Biphasic Equivalent 7. Resume CPR ***A Fluid Challange of 20cc/kg Should be Administered Over 10 Minutes in All Cardiac Arrest Situations. May Repeat Once. Rhythm Change? *Patients > 1 YOA In all witnessed or known short duration (<4-5 minutes) cardiac arrest where defibrillation is indicated immediate defibrillation should be performed. In all other arrest situations where defibrillation is indicated the provider should perform 5 cycles (2 minutes) of CPR prior to defibrillation. 1. Resume CPR 2. IV, NS, TKO*** 3. Intubate Patient 4. Epinephrine: Repeat Every 3 to 5 Minutes IV/IO: 0.01mg/kg to a max of 1mg per single dose(1:10,000, 0.1mL/kg) ET: 0.1mg/kg (1:1,000, 0.1mL/kg) to a max of 1mg per single dose Joules/kg, to a max of 360 Joules or Biphasic Equivalent 6. Resume CPR Rhythm Change? 1. Resume CPR 2. Amiodarone, 5mg/kg to a max of 300mg. May repeat once in 3-5 minutes at 2.5mg/kg to a max of 150mg.**** 3. 4 Joules/kg, to a max of 360 Joules or Biphasic Equivalent 4. Resume CPR Continue to Treat, Monitor & Transport Rhythm Change? Check Pulse *** If IV or IO access unavailable administer Lidocaine 2mg/kg, ET. If V-Tach not suppressed repeat Lidocaine 2mg/kg, ET, every 3-5 minutes to a max of 6mg/kg, ET Once an antiarrhythmic is administered DO T administer a different antiarrhythmic. If IV or IO access is obtained after ET Lidocaine was administered, administer Lidocaine 1mg/kg, IV, may repeat every 3-5 minutes to a max of 3mg/kg, IV (Should not administer more than 3 total doses whether IV/IO or ET) The Administration of Lidocaine during IO placement for pain control ONLY does not contraindicate the administration of Amiodarone if indicated Refer to Appropriate 02/01/2011 ** Ideally chest compressions should be interrupted only for rhythm checks and actual defibrillations. The 2005 guidelines state that when CPR is indicated the provider should perform 5 cycles (2 Minutes) of chest compressions. Continue CPR while drugs are prepared/administered and the defibrillator is charging. Providers must organize care to ensure that chest compressions, initial and subsequent defibrillations are not delayed in order to administer drugs, place advanced airways or obtain vascular access. 17 Page 18

18 ASYSTOLE or PULSELESS ELECTRICAL ACTIVITY - PEDIATRIC EMT- Paramedic ***IV Fluids Should be Infused at a Rate to Obtain a Fluid Bolus of 20cc/kg Over 10 Minutes. May Repeat Once if Needed. 1. ABCs 2. CPR (2005 Guidelines)* 3. Ventilate with Oxygen (Insert OPA/NPA) 4. Use ResQPOD if the patient has reached puberty 5. Attach Defibrillator** 6. IV, NS*** 7. Intubate Patient 8. Resume CPR Rhythm Change or Pulse Present? **** Consider Whether One of the Following may be Involved and Treat Appropriately: Hypovolemia (Infuse Volume) Hypoxia (Ventilate) Hypo/Hyperkalemia Hydrogen Ion (Acidosis) Hypoglycemia (D50) Hypothermia Toxins/OD Tamponade (Cardiac) Tension Pneumothorax (Decompress Chest) Thrombosis (Pulmonary, Coronary) Trauma 1. Resume CPR 2. Epinephrine: Repeat Every 3 to 5 Minutes IV/IO: 0.01mg/kg up to a max of 1mg per single dose. (1:10,000, 0.1mL/kg) or ET: 0.1mg/kg up to a max of 1mg per single dose. (1:1,000, 0.1mL/kg) Rhythm Change or Pulse Present? Resume CPR Treat Possible Contributing Factors**** Refer to Appropriate Continue to Treat, Monitor & Transport **Asystole should be confirmed in 2 leads. If rhythm is unclear and possibly Ventricular Fibrillation, go to Ventricular Fibrillation. * Ideally chest compressions should be interrupted only for rhythm check. The 2005 guidelines state that when CPR is indicated the provider should perform 5 cycles (2 minutes) of chest compressions. Continue CPR while drugs are prepared/administered. Providers must organize care to minimize interruption in chest compressions for rhythm checks, advance airway insertion, or vascular access. 02/01/2011 Page 8 18

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20 BRADYARRHYTHMIA - PEDIATRIC EMT- Paramedic 1. ABCs 2. Oxygen 3. Assist Ventilations if Respirations Inadequate (Insert OPA/NPA if needed) 4. Intubate Patient if Unable to Maintain Airway 5. IV, NS, TKO (Use IO Access if Necessary) 6. Assess Vital Signs & Perfusion Patient has any of the Following: Signs/Symptoms of Hypoperfusion? Hypotension? Respiratory Difficulty? Perform Chest Compressions if, Despite Oxygenation & Ventilation, Heart Rate: <80/min in an Infant (<1 year old) <60/min in a Child (1-12 years old) Pulse >60 (>80 in Infant), or Signs/Symptoms Resolve? Epinephrine: IV/IO: 0.01mg/kg (1:10,000, 0.1mL/kg) to a max of 5cc per single dose. or ET: 0.1mg/kg (1:1,000, 0.1mL/kg) to a max of 0.5cc per single dose. Repeat Every 3-5 Minutes at Same Dose Pulse >60 (>80 in Infant), or Signs/Symptoms Resolve? Atropine, 0.02mg/kg, IV Minimum Dose 0.1mg Maximum Single Dose 0.5mg May Repeat every 3-5 Minutes (In children 0-8 years of age to a max of 1mg) (In Adolescence 9-15 years of age to a max of 2mg) Continue to Treat, Monitor & Transport 02/01/2011 Page 10 20

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22 1. Oxygen 2. IV, NS, TKO Patient Conscious? SUPRAVENTRICULAR TACHYCARDIA (>150) 1. Synchronized 100 Joules 2. Synchronized 200 Joules* 3. Synchronized 300 Joules* 4. Synchronized 360 Joules* EMT- Paramedic *Repeated Cardioversions Are Done Only if There is Rhythm Change. Rhythm Change? Refer to Appropriate Valsalva Maneuver Rhythm Change? Adenosine, 12mg, IV Rhythm Change? Refer to Appropriate Refer to Appropriate Adenosine, 12mg, IV Rhythm Change? Refer to Appropriate If Systolic BP >90mmHg and patient is conscious give Versed, 5mg, IVP (2.5mg if > 60 years old) Altered Mental Status, Chest Pain, Hypotension, or Other Signs of Shock Continue to Treat, Monitor & Transport 1. Synchronized 100 Joules 2. Synchronized 200 Joules* 3. Synchronized 300 Joules* 4. Synchronized 360 Joules* Rhythm Change? **Amiodarone, 150mg IV Over 10 minutes. May Repeat Once if Needed. (may mix into 100cc of D5W) Rhythm Change? Refer to Appropriate Continue to Treat, Monitor & Transport Refer to Appropriate PEDIATRIC DOSES Sync. 1Joule/kg to a max of 100 J Sync. 2Joules/kg to a max of 360 J* Adenosine, 0.1mg/kg to a max of 12mg Versed, 0.1mg/kg, IV, to a max of 2.5mg Amiodarone 5mg/kg, IV, over 20 minutes, to a max single dose of 150mg. May be repeated X 2 (Do not mix into 100cc of D5W) 02/01/2011 PEDIATRIC SVT RATES In Infants Heart rate > 220 In Children Heart Rate > 180 ** The Administration of Lidocaine during IO placement for pain control ONLY does not contraindicate the administration of Amiodarone if indicated Page 16 22

23 VENTRICULAR TACHYCARDIA WITH A PULSE EMT- Paramedic 1. Oxygen 2. IV, NS, TKO Patient Experiencing Any of the Following: Systolic BP <90mmHG? Chest Pain? Dyspnea? Signs/Symptoms of CHF? Other Signs/Symptoms of Hypoperfusion? Continued on Following Page C Amiodarone 150mg, IV, over 10 minutes. If patient remains without above signs and symptoms. Amiodarone may be repeated every 10 minutes as needed to a max of 450mg. (May mix into 100cc of D5W) Ventricular Tachycardia Suppressed? Class I or II Cardiac Rhythm (P-11) with stable vital signs? Refer to Appropriate Does Patient Have any Signs and Symptoms Listed Above? Continue to Treat, Monitor & Transport Continue to Treat, Monitor & Transport * * If at any time the patient starts to experience any of the signs and symptoms noted above, go directly to Cardioversion.( Pg 20) PEDIATRIC DOSE Amiodarone 5mg/kg, IV, over 20 minutes, to a max single dose of 150mg. May be repeated X 2 (Do not mix into 100cc of D5W) 02/01/ Page 19

24 VENTRICULAR TACHYCARDIA WITH A PULSE (CONTINUED) EMT- Paramedic C If systolic BP >90mmHg consider Versed, 5 mg, IV (2.5 mg if >60 years old) 1. Synchronized 100 Joules 2. Synchronized 200 Joules** 3. Synchronized 300 Joules** 4. Synchronized 360 Joules** **Repeated Cardioversions Are Done Only if There is Rhythm Change. Ventricular Tachycardia Suppressed? Class I or II Cardiac Rhythm (P-11) with stable vital signs? Refer to Appropriate Refer to Post Resuscitation Management (pg-13) Intubate Patient If Needed*** 1. Amiodarone 150mg, IV, over 10 minutes. Amiodarone may be repeated every 10 minutes as needed to max of 450mg. (May mix into 100cc of D5W) 2. Synchronized 360 Joules,** or Energy Setting Previously Successful, Following Each Dose of Amiodarone. Ventricular Tachycardia Suppressed? Class I or II Cardiac Rhythm (P-11) with stable vital signs? Refer to Appropriate Continue to Treat, Monitor & Transport Continue to Treat, Monitor & Transport PEDIATRIC CARDIOVERSION Infant- 1J/kg up to a max of 100J Child- 2J/kg up to a max of 360J *** If IV or IO access unavailable administer Lidocaine 2mg/kg, ET. If V-Tach not suppressed repeat Lidocaine 2mg/kg, ET, every 3-5 minutes to a max of 6mg/kg, ET Once an antiarrhythmic is administered DO T administer a different antiarrhythmic. If IV or IO access is obtained after ET Lidocaine was administered, administer Lidocaine 1mg/kg, IV, may repeat every 3-5 minutes to a max of 3mg/kg, IV (Should not administer more than 3 total doses whether IV/IO or ET) The Administration of Lidocaine during IO placement for pain control ONLY does not contraindicate the administration of Amiodarone if indicated PEDIATRIC DOSE Amiodarone 5mg/kg, IV, over 20 minutes, to a max single dose of 150mg. May be repeated X 2 (Do not mix into 100cc of D5W) Versed, 0.1mg/kg, IV, to a max of 2.5mg Lidocaine 2mg/kg, ET, every 3-5 minutes, to max of 6mg/kg. If IV or IO access is obtained after ET Lidocaine was administered, administer Lidocaine 1mg/kg, IV, may repeat every 3-5 minutes to a max of 3mg/kg, IV (Should not administer more than 3 total doses whether IV/IO or ET) Once an antiarrhythmic is administered DO T administer a different antiarrhythmic. 02/01/ Page 20