Vascular Access

Difficulty in obtaining rapid intravenous (IV) access is certainly one of the major differences between adult and pediatric resuscitation (see Chap 17, "Vascular

Access"). Two important facts should be kept in mind. First, a significant portion of children respond to airway management alone, since most cardiac arrests in children are secondary to hypoxic respiratory arrest. Time spent securing vascular access at the expense of adequate airway management is a common mistake in dealing with children. Second, once a patient has been intubated, the tracheal route may be used to administer drugs such as lidocaine, epinephrine, atropine, and naloxone (mnemonic: LEAN). The dose of endotracheal epinephrine for symptomatic bradycardia or pulseless cardiac arrest is 0.1 mg/kg, 1:1000 concentration q 3 to 5 min. Although the ideal doses for other drugs have never been studied in children, current recommendations support the use of two to three times the IV dose. 4

Although central access would be ideal for administration of drugs during CPR, many emergency medicine practitioners are not highly skilled in placing central lines in children. Therefore, the most frequently used sites are peripheral: scalp, arm, hand, or antecubital veins; the external jugular vein; femoral vein; or distal saphenous vein via cutdown. Intraosseous infusion is a quick, safe route for resuscitation drugs as well as fluid administration. This is discussed in Chap 17, "Vascular Access."

The general order of attempts during a resuscitation should be antecubital, hand, or foot and then intraosseous.

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