Resuscitation
Intraosseous access can be used to infuse medications, electrolyte solutions, and blood
products. The absorption and duration of action are described as similar to those in
peripheral and central venous routes. Second choice after failure to obtain peripheral access
in the injured child.

(Epinephrine, atropine, naloxone, lidocaine, and vasopressin) may be used by endotracheal
administration.
Norepinephrine is the preferred vasoactive drug in a child with fluid-refractory septic shock
and warm extremities.

Epinephrine is the vasoactive agent of choice for treating patients in septic shock with cold
extremities.

In children with norepinephrine-refractory shock, use of vasopressin may be considered, but
it should not be the first vasopressor administered.

Milrinone may be useful in the patient with adequate blood pressure but persistent signs of
shock.
Access
Fluid-refractory septic shock
Airways
Oral airways should not be used in patients with intact airway protective reflexes or gag reflex.

Nasal airways (NA) can be used in semiconscious patients with intact gag or airway reflexes.
They should not be used in children with suspected basal skull fracture, or those with nasal
fracture or recent surgery.

The NA tip is beveled and should be inserted with bevel facing the nasal septum. The NA is
curved in such a way that the right nostril should be used, if possible.
On occasion, if there is antidromic (retrograde conduction of the impulse through the
atrioventricular [AV] node) AV re-entry, the EKG tracing will demonstrate wide complexes and
will look like ventricular tachycardia.

After conversion to a sinus rhythm, the EKG in those patients with WPW will reveal the
classic delta wave with a short PR interval and upsloped initial portion of the QRS complex.

Unstable SVT, characterized by signs of cardiogenic shock and congestive heart failure,
requires immediate synchronized cardioversion. Initial attempts at 0.5 to 1 J/kg. If repeated
attempts are needed, the energy should be doubled, up to 2 J/kg.
SVT