Infant defibrillation

[Kaisu]

Although anecdotal and not a controlled study by any means, my paramedic instructor with 35 years in the field (NREMT patch number 5) has shocked about 300 infants (under 1) in the field and in the ED. ROSC = 0, but he says shock 'em anyway - what have you got to lose?

[tniuqs]

Squint: The Problem is that these AEDs have preset joules hence the PALS guidelines > 1 year of age AED not advised.

CORRECTION: that should say PALS guidelines < 1 year of age for a "flash box" my bad

Did someone say something about flash boxes measuring chest impedance to calculate joules or some thing ... like I say I hate those stoopid things and didn't medtronics have a huge recall because of that issue ? I dunno?

Although anecdotal and not a controlled study by any means, my paramedic instructor with 35 years in the field (NREMT patch number 5) has shocked about 300 infants (under 1) in the field and in the ED. ROSC = 0, but he says shock 'em anyway - what have you got to lose?

Ok question in v-fib V tach or asystolic maybe I am misreading ?

Your licence for practicing beyond scope and protocol? so the ethics question gets tossed in, and an investigation or post mortum the coroner could ask why are there burns on this kids chest or subpoena code summary of ecg records, if you cant justify actions you just may find your medical director was not in favor of supporting you that day.

cheers

[Kaisu]

He made the statement "in cardiac arrest". I just assumed pulseless vtach/vfib because no-one shocks asystole - although they may have 30 years ago.

In this instructional setting, everything was taught with the caveat of if within protocols.

If I run on an infant in pulseless vtach/vfib, I would shock them. It is in our protocols. As others have mentioned, 2 joules/kg for the first shock, 4 joules/kg for subsequent shocks. I would imagine the odds of me running on an infant in a shockable rhythm are pretty low. I've had one pediatric arrest in 1300 calls and 15/2 CPR restored a pulse.

[Brandon Oto]

I was assuming BLS since that's my bailiwick, so the idiot box isn't going to shock asystole unless you jiggle it just right. But the medics have more options available anyway.

Great input guys. You're probably right that no matter how you squint at it, the "right" answer is going to involve bringing medical control into the huddle.

[kohlerrf]

I recently had a centrally cyanotic 10 month old baby boy in Stat Ep refractory to Diastat in respiratory arrest, fortunately through RSI I was able to control the airway and the pt did not arrest, but, Yes, had the pt arrested and after I had control of the airway and done 2 min of CPR and ruled out respiratory causes and done what I could with metabolic causes and 5H's and 5T's, if I had a shockable rhythm and I had the proper size pads and a defibrillator where I could select a weight based charge and I had not arrived at the hospital yet, Yes I would defibrillate the still dead lifeless body in front of me.

[Jwade]

I recently had a centrally cyanotic 10 month old baby boy in Stat Ep refractory to Diastat in respiratory arrest, fortunately through RSI I was able to control the airway and the pt did not arrest, but, Yes, had the pt arrested and after I had control of the airway and done 2 min of CPR and ruled out respiratory causes and done what I could with metabolic causes and 5H's and 5T's, if I had a shockable rhythm and I had the proper size pads and a defibrillator where I could select a weight based charge and I had not arrived at the hospital yet, Yes I would defibrillate the still dead lifeless body in front of me.

AS a PALS instructor, The Pediatric AED pads have essentially a " Voltage Regulator" that will dial down the joules from 360 - 50 joules....If they are in VFIB / Pulseless Vtach and the 6H's and 5T's have been ruled out, you NEED to be shocking the patient....End of story, regardless of age.....The bottom line after all the BS and anecdotal crap, is you still have a lethal rhythm that is potentially reversible.....

Not quite sure why so many people are afraid of the NEO / PEDI population, Dead is Dead, they will continue to remain DEAD if you do nothing.......

Respectfully,

JW

[crotchitymedic1986]

I seriously doubt your instructor has actually shocked 300 infants in his career, but his point is correct. Shockable rhythms are rarely seen in children under 1 (unless you count tachycardias, but you shouldnt be shocking those, or if they had a preexisting cardiac conditions). The question you have to ask is one that has been asked before on here, in any situation, where are you most likely to get into trouble ? Not everything in EMS is black and white ? In this scenario if you had a child in V-Fib, do you think you would get in more trouble for using the equipment you have on hand to try to save the child, or letting the child die because you had issues with AHA guidelines (or protocols), or lackthereof ? This is what Medical Control is for.

[Kaisu]

I seriously doubt your instructor has actually shocked 300 infants in his career, but his point is correct.

I believe him. Not only is this guy one of the first paramedics in the country, but for the last 25 years he has been the lead instructor at Wisconsin's premier paramedic program. This is a guy that has spent the last 25 years doing 3 - 8 hour shifts per week in a very busy ED with students - yeah, a paramedic program that does NOT send students to clinicals without an instructor. Look up Jeffery B. Clark in the NREMT publication for a profile done about 5 years ago. At that time he was termed a visionary. He has no ego issues that would make him inflate the number.

This is what Medical Control is for.

Given that you have the time and the hands to play "mother may I"

[kohlerrf]

AS a PALS instructor, The Pediatric AED pads have essentially a " Voltage Regulator" that will dial down the joules from 360 - 50 joules....If they are in VFIB / Pulseless Vtach and the 6H's and 5T's have been ruled out, you NEED to be shocking the patient....End of story, regardless of age.....The bottom line after all the BS and anecdotal crap, is you still have a lethal rhythm that is potentially reversible.....

Not quite sure why so many people are afraid of the NEO / PEDI population, Dead is Dead, they will continue to remain DEAD if you do nothing.......

Respectfully,

JW

so we agree?

[tniuqs]

AS a PALS instructor, The Pediatric AED pads have essentially a " Voltage Regulator" that will dial down the joules from 360 - 50 joules....If they are in VFIB / Pulseless Vtach and the 6H's and 5T's have been ruled out, you NEED to be shocking the patient....End of story, regardless of age.....The bottom line after all the BS and anecdotal crap, is you still have a lethal rhythm that is potentially reversible.....

Not quite sure why so many people are afraid of the NEO / PEDI population, Dead is Dead, they will continue to remain DEAD if you do nothing.......

Respectfully,

JW

So as a PALS instructor and for the sake of debate if the internal voltage regulator on an AED, essentially this is incorrect although a nit picky point are not in the pads in the first place they are just sensed through the pads and is not chest impedance measured in joules of the AED, just how does it do that I must wonder would placement of gel pads affect this measurement, or proper contact, remembering that these are approved for public use.

And if 50 joules is the lowest setting and I believe you are speaking for just one flavor of AED on the market, and last count about 20 manufactures with varying algorithm ? You did hear of the FDA recall one variety for failure (rumored) to give enough energy, you can understand I am so not a fan of AEDs, I am a fan of providing Advanced Care, on the other hand perhaps loosing money in the stock market has made me bitter.

So following your PALS advice as an instructor the lowest setting would be 50 joules and following PALS guidelines of 2J/kg first shock that would amount to a pt weight of 25 kg or converted 55 pounds that would put on my plastic card into the BLUE level ... btw I do have some experience in NICU, PICU settings and have yet to see a 55 pound infant, I think my daughter was 3 years old before she was that weight.

That said I do not disagree at the Paramedic level if an infant was in a shockable rhythm then by all means then agreed but in asystolic just further attempt is just for show, ie you can do everything by the book but fact is our resus rates in the peads demographic are abysmal, even within a hospital setting, dead IS dead, if one has not had a positive response to fluid or pharmacology before arrival to ER ..

And just my anecdotal experience is when vast majority of situations infants respond to stress with tachycardia then bradcardia then flat line in a time frame so quickly never to accommodate the mother may I technique.

And in closing after my last "recert" in PALS there were many errors in instruction and just following the PALS Bible one must look beyond one reference only IMHO.

cheers