Non-Pharmacological Management

Respiratory Failure

• Positioning: Allow patient to assume position of comfort, optimize airway patency. Place in sniffing position if used bag-valve mask.
• Suctioning: Clear airway of secretions.
• Oxygen: Provide supplemental oxygen via nasal cannula, facemask, non-rebreather mask. Titrate to target SpO2 94-99%.
• Bag-valve mask ventilation: Provides positive pressure ventilation with high concentration oxygen. Two person technique preferred.
• Airway adjuncts: Oral or nasal airways can help maintain patency if gag reflex impaired.
• Noninvasive ventilation: CPAP or BiPAP may help some patients with upper airway obstruction or impending respiratory failure.
• Endotracheal intubation: Definitive airway management for patients in respiratory failure unable to protect airway or maintain oxygenation/ventilation. Perform rapid sequence intubation in critically ill children.
• Mechanical ventilation: Required after intubation. Start with age-based settings then titrate based on chest rise and ETCO2.

Shock

• Oxygen: Provide supplemental oxygen via nasal cannula, facemask, or non-rebreather mask.
• Patient positioning: Place in Trendelenburg or supine position. Elevate lower extremities.
• IV/IO access: For fluid resuscitation, medication administration.
• Fluid resuscitation: Initial bolus 10-20 mL/kg isotonic crystalloid. Reassess and give additional boluses as needed.
• Vasopressors: Used if fluid refractory shock. Start with dopamine or epinephrine. Titrate to effect.
• Treat underlying cause: Antibiotics for sepsis, blood products for hemorrhage, etc.
• Monitoring: Continuously monitor vitals, mental status, peripheral perfusion. Trend lactate.

Cardiac Arrest

• High-quality CPR: Ensure adequacy of compressions and avoid excessive ventilations.
• Defibrillation: For ventricular fibrillation, pulseless ventricular tachycardia. Use pediatric pads/attenuator if possible.
• Advanced airway: Endotracheal intubation or supraglottic airway device. Confirm tube placement.
• Mechanical CPR devices: Can provide high-quality, uninterrupted compressions. Requires proper sizing.
• ECMO CPR: Option for refractory arrest in settings with ECMO capabilities, especially for patients with cardiac disease.
• Temperature monitoring/regulation: Target 32-34°C if implementing therapeutic hypothermia. Avoid fever.
• TTM: Targeted temperature management for 24 hours post-arrest.

Bradycardia

• Oxygen: Provide supplemental oxygen via nasal cannula, facemask, or non-rebreather mask.
• Chest compressions: If HR <60 bpm with poor perfusion.
• Atropine: If increased vagal tone or primary AV block.
• Pacing: Transcutaneous or transvenous pacing for unstable or refractory bradycardia.
• Treat underlying cause: Hypoxemia, acidosis, hypoglycemia, hypothermia, electrolyte abnormalities.

Tachycardia

• Oxygen: Provide supplemental oxygen via nasal cannula, facemask, or non-rebreather mask.
• Vagal maneuvers: Ice water to the face, diving reflex. First-line for stable SVT.
• Adenosine: First-line medication for stable, regular SVT. Rapid IV push.
• Synchronized cardioversion: For unstable SVT, VT, or wide complex tachycardia of uncertain origin.
• Expert consultation: Obtain cardiology consult for unstable or refractory cases.