2020 AHA Guidelines (Dr. Price)

• Confirmation
  • CPR depth 2 to 2.4
  • CPR Rate 100 to 120
• New changes
  • Recommend lay rescuers initiate CPR for presumed cardiac arrest
  • Double sequential defibrillation for nonresponsive vfib/vtach not recommended anymore
  • Reasonable to attempt IV access prior to IO access first
  • Recommending epinephrine in non-shockable rhythms as soon as possible
  • Give epinephrine for shockable rhythm after defibrillation fails
  • Recommends against use of POCUS for prognostication, can be used to detect ROSC. 
  • Delay neuro-prognostication in coma for 72 hours
  • Should avoid excessive ventilation during cpr- causes harm
  • Amiodarone or lidocaine may be considered for CF/pVT unresponsive to defibrillation
  • Routine administration of Ca, NA bicarbinate, Magnesium not recommend in cardiac arrest
• Pediatric changes
  • 1 breath every 2-3 seconds (20-30 breaths per minute)
  • Reasonable to use Cuffed- ET tubes
  • Epinephrine may increase survival to discharge rates (unlike adults)
• Field termination rule
  • If patient had arrest not witnessed, no bystander CPR, No ROSC, No shock was delivered can consider stopping. 

Sickle cell disease in pediatrics (Amar Singh)

1. Vasocclusive pain crisis
   • Causes- sickling leads to occlusion leading to ischemia and pain. 
   • Dactylitis- sickling and infarction of hands. Usually first presentation in kids 6months to 2 years of age
   • Mgt: Fluids and pain control with NSAIDS/narcotics
2. Stroke- 300 fold increase risk . 
   • Tx is exchange transfusion and hydration. TPA not recommended. 
3. Acute chest syndrome
   • Pulmonary infiltrate and any respiratory symptom. Indicative of infection and or infiltrate. 
   • Mgt: 02, hydration, antibiotics, blood transfusion or exchange transfusion. 
4. Splenic sequestration
   • See acute hemoglobin drop at least 2 points with LUQ pain, splenomegaly
   • Tx: IVF with blood transfusion, find underling cause (Likely infection)
5. Sepsis
   • Streptococcus pneumonia- most common cause of sepsis in asplenic patient. 
   • Other encapsulated Strep, H.Flu, salmonella, ecoli.
   • Increased risk for salmonella osteomyelitis 
6. Aplastic Crisis 
   • Commonly caused by parvovirus b-19 with marked severe anemia with decreased reticulocyte count. 
   • Mgt- transfusion and IVIG to help clear parvovirus infection. 

Hyperglycemic emergencies (Dr. Mcgee)

1. DKA
   • Hyperglycemia >250mg/dl
   • Ketonemia- produced by excessive breakdown of fatty acids (includes acetoacetate, acetone, BHOB)
   • Acidosis pH <7.3
     • Can be normal 2/2 to compensation and contraction alkalosis, elevated anion gap may be only clues
   • Other types of ketoacidosis    
     • Alcoholic ketoacidosis, starvation ketoacidosis, isopropyl alcohol ingestion (ketonemia)
   • Mgt: focus should be on closing the gap. 
     • 1. Volume repletion most patients 3-6L down. When sugars < 250 include dextrose containing fluids. 
     • 2. Electrolyte repletion K<3.5 consider stopping insulin, K3.5 to 5.5, consider adding K to fluids 20-30meq/L. <5.5 no need to add potassium. Check Mg, Phos levels as well. 
     • Insulin drip >1units/kg dose. Switch to subQ after gap normalized and bicarbonate normalized. 
2. Hyperosmolar hyperglycemic state
   • Triad
     • Severe hyperglycemia (> 600 usually)
     • Elevated serum osmolality (>320 osm/kg)
     • Altered mental status 
   • Treat similarly to DKA, usually require more fluids as patients more dehydrated.  

Resuscitative Hysterotomy (Ben Turner and Harrison Brown)

1. Indications to do
   • Maternal cardiac arrest without ROSC within 4 minutes
   • Estimated gestational age of infant >20 weeks (fundus > 20 cm)
   • Not necessary to document FHT prior to procedure.      
2. Contraindications 
   • Known age < 20 weeks
   • ROSC within 4 minutes of arrest
3. Procedure
   • https://www.youtube.com/watch?v=IwDWv2iyAos

• Secrete meeting of the minds.