1. Three rapid assessment questions:

   • Term gestation?
   • Good muscle tone?
   • Breathing or crying?

2. Next step:

   • Routine care: Stay with mother for skin-to-skin contact, provide warmth, clear secretions if needed, dry the baby, and ongoing assessment of breathing, tone, and color.

1. Four pre-birth questions (NRP 8th Edition):

   • 1. Gestational age?
   • 2. Is amniotic fluid clear?
   • 3. Are there any additional risk factors?
   • 4. What is our umbilical cord management plan (delayed cord clamping vs milking)?

2. Preparation:

   • Switch on radiant warmer, wash hands, and team briefing.
   • Equipment check: Food-grade plastic bag/wrap and thermal mattress ($<32\text{ weeks}$), T-piece resuscitator / self-inflating bag with reservoir, blended oxygen set at 21–30%, pulse oximeter and ECG monitor leads, suction catheter (10F/12F), laryngoscope with size 0/00 blade, and ET tubes (sizes 2.5, 3.0).

3. Initial steps (Preterm $<32$ weeks):

   • Place baby directly in polyurethane bag/wrap under radiant warmer without drying the body (dry head only and put on a cap).
   • Position airway (sniffing position).
   • Suction mouth then nose only if obstructed.
   • Gentle tactile stimulation.

4. PPV Initiation:

   • Start PPV with T-piece resuscitator / bag at 40–60 breaths/min with initial $\text{FiO}_2 = 21\text{–}30\%$.
   • Attach pulse oximeter probe to right upper extremity (pre-ductal).
   • Attach 3-lead electronic cardiac monitor for continuous heart rate display.

5. Ventilation Corrective Steps (MR. SOPA):

   • M: Mask adjustment (ensure tight seal)
   • R: Reposition airway (neutral/sniffing position)
   • (Re-evaluate PPV for 5 breaths; if no chest rise:)
   • S: Suction mouth and nose
   • O: Open the mouth slightly and lift jaw
   • (Re-evaluate PPV; if no chest rise:)
   • P: Pressure increase (in increments of $5\text{–}10\text{ cmH}_2\text{O}$ up to $30\text{–}40\text{ cmH}_2\text{O}$)
   • (Re-evaluate PPV; if no chest rise:)
   • A: Alternative airway (Endotracheal tube or Laryngeal Mask)

6. Next step for labored breathing:

   • Position and clear airway, provide supplemental blended oxygen if needed to meet target $\text{SpO}_2$, and initiate Continuous Positive Airway Pressure (CPAP) at $5\text{–}6\text{ cmH}_2\text{O}$.

Refer to the standard NRP 8th Edition Flowchart:

1. Target Pre-ductal $\text{SpO}_2$ after Birth:
   • 1 min: 60%–65%
   • 2 min: 65%–70%
   • 3 min: 70%–75%
   • 4 min: 75%–80%
   • 5 min: 80%–85%
   • 10 min: 85%–95%
2. Initial $\text{FiO}_2$ for PPV: $\ge 35\text{ weeks} = 21\%$; $<35\text{ weeks} = 21\text{–}30\%$.
3. Chest Compression Ratio: 3:1 (3 compressions : 1 ventilation, 90 compressions and 30 breaths per minute).
4. Epinephrine Dose:
   • IV/IO: $0.02\text{ mg/kg}$ ($0.2\text{ mL/kg}$ of 1:10,000 solution) followed by $3\text{ mL}$ normal saline flush.
   • Endotracheal (ET): $0.1\text{ mg/kg}$ ($1\text{ mL/kg}$ of 1:10,000 solution).

1. Pre-resuscitation Preparation:

   • Form resuscitation team & designate team leader / roles.
   • 4 Pre-birth questions: Gestational age, amniotic fluid clarity, number of babies/risk factors, cord clamping plan.
   • Equipment Checklist (Warm, Clear airway, Auscultate, Ventilate, Oxygenate, Intubate, Medicate):
     • Radiant warmer pre-heated, plastic wrap and warming pad.
     • Suction apparatus set at 80–100 mmHg with 10F/12F catheters.
     • T-piece resuscitator / self-inflating bag with reservoir and appropriate masks (sizes 0/1).
     • Oxygen blender and flowmeter ($10\text{ L/min}$).
     • Pulse oximeter and ECG leads.
     • Laryngoscope with size 00/0 blades, ET tubes (2.5, 3.0), stylet, $\text{CO}_2$ detector.
     • Emergency drugs (Epinephrine 1:10,000, Normal saline), UVC catheterization kit.

2. Handling 28-week Preterm Infant:

   • Delayed cord clamping (30–60 seconds if hemodynamically stable).
   • Place infant directly (without drying) into food-grade polyethylene bag/wrap under radiant warmer; place cap on head.
   • Position head in sniffing position, clear airway if obstructed.
   • Assess breathing, heart rate, and tone within 30 seconds. If apneic/gasping or $\text{HR} < 100\text{ bpm}$, initiate PPV with blended $\text{O}_2$ (21–30%) and apply pulse oximeter probe on right wrist.

1. Incubator & Radiant Warmer Instructions:

   • Radiant Warmer / Incubator Modes:
     • Servo/Skin Mode: Preferred; temperature probe attached securely over right hypochondrium / liver area (avoid bony prominences/brown fat). Target abdominal skin temperature $36.5\text{–}37.5^\circ\text{C}$.
     • Manual Mode: Used only for initial preheating before delivery; never leave unattended in manual mode due to hyperthermia risk.
   • Incubator Care: Maintain air temperature at neutral thermal environment based on birth weight/gestational age; access through portholes; minimize draughts; maintain humidity for extreme preterms ($>70\text{–}85\%$ in week 1).
   • Care on Bubble CPAP:
     • Ensure proper prong size (fill 100% of nares without pinching septum).
     • Prevent nasal trauma: Use hydrocolloid barrier/nasal mustache, check columella hourly.
     • Check bubble chamber for continuous bubbling (confirms circuit patency and PEEP).
     • Orogastric tube left open to vent for gastric decompression.
     • Change position 4–6 hourly; encourage Kangaroo Mother Care (KMC) once stable.

2. Resuscitation for Acute Fetal Distress:

   • Wash hands, receive baby under radiant warmer in warm dry towel.
   • Check Term? Tone? Crying? If not breathing/gasping $\rightarrow$ provide initial steps (warm, dry, stimulate, position airway, suction mouth then nose).
   • Check HR and respiration: If $\text{HR} < 100\text{ bpm}$ or gasping $\rightarrow$ initiate PPV ($21\%\text{ FiO}_2$, $40\text{–}60\text{ breaths/min}$) + apply pre-ductal pulse oximeter.
   • After 15 seconds: If no chest rise $\rightarrow$ MR. SOPA.
   • After 30 seconds of effective PPV: If $\text{HR} < 60\text{ bpm} \rightarrow$ intubate, increase $\text{FiO}_2$ to 100%, and begin coordinated chest compressions (3:1 ratio).
   • After 60 seconds of compressions: If $\text{HR} < 60\text{ bpm} \rightarrow$ administer IV Epinephrine ($0.02\text{ mg/kg}$ via UVC) followed by $3\text{ mL}$ normal saline flush.

1. Diagnosis: Pulseless Ventricular Tachycardia (pVT) / Ventricular Fibrillation (VF) or Pulseless Electrical Activity (PEA) depending on rhythm interpretation; the scenario presents a shockable cardiac arrest rhythm (pVT/VF).
2. PALS Shockable Rhythm Management:
   • Start CPR: High-quality CPR, give 100% oxygen, attach defibrillator/monitor pads.
   • 1st Shock: Defibrillate immediately with $2\text{ J/kg}$.
   • Resume CPR immediately: 2 minutes of CPR (15:2 ratio with 2 rescuers; continuous compressions 100–120/min if advanced airway in place). Obtain IV/IO access.
   • Check Rhythm: If still VF/pVT $\rightarrow$ 2nd Shock: $4\text{ J/kg}$.
   • Resume CPR: Give Epinephrine $0.01\text{ mg/kg}$ ($0.1\text{ mL/kg}$ of 1:10,000 IV/IO) every 3–5 minutes. Consider advanced airway and capnography.
   • Check Rhythm: If still shockable $\rightarrow$ 3rd Shock: $\ge 4\text{ J/kg}$ (up to $10\text{ J/kg}$ or adult max).
   • Resume CPR: Administer Amiodarone $5\text{ mg/kg}$ bolus IV/IO (or Lidocaine $1\text{ mg/kg}$).
   • Treat reversible causes (Hs and Ts).

1. Diagnosis: Asystole (cardiac arrest / flat line).
2. PALS Non-Shockable Rhythm Management (Asystole / PEA):
   • Immediate High-Quality CPR: 15:2 compression-to-ventilation ratio with 100% oxygen.
   • Epinephrine as early as possible: $0.01\text{ mg/kg}$ ($0.1\text{ mL/kg}$ of 1:10,000) IV/IO, repeat every 3–5 minutes.
   • Advanced Airway: Endotracheal intubation or SGA with continuous waveform capnography ($\text{ETCO}_2$).
   • Rhythm & Pulse Check: Every 2 minutes (switch compressor).
   • Search and treat reversible causes (Hs & Ts):
     • Hs: Hypovolemia, Hypoxia, Hydrogen ion (acidosis), Hypoglycemia, Hypo/Hyperkalemia, Hypothermia.
     • Ts: Tension pneumothorax, Tamponade (cardiac), Toxins, Thrombosis (pulmonary / coronary).

The 4 cardiac arrest rhythms are:

1. Shockable Rhythms:
   • Ventricular Fibrillation (VF)
   • Pulseless Ventricular Tachycardia (pVT)
2. Non-Shockable Rhythms:
   • Asystole
   • Pulseless Electrical Activity (PEA) / Electromechanical Dissociation (EMD)

1. Asystole (most common in pediatric hypoxic/drowning arrest)
2. Pulseless Electrical Activity (PEA)
3. Severe sinus bradycardia progressing to agonal rhythm
4. Ventricular Fibrillation (VF) / Pulseless VT (especially if associated with profound hypothermia or underlying channelopathy / Long QT syndrome)

1. ECG Diagnosis: Paroxysmal Supraventricular Tachycardia (PSVT) — narrow QRS complex tachycardia with absent P waves and heart rate $>220\text{ bpm}$ in infants.
   • Drug of choice: IV Adenosine.
2. Adenosine Dosing & Administration:
   • 1st Dose: $0.1\text{ mg/kg}$ rapid IV push (maximum first dose $6\text{ mg}$).
   • 2nd Dose: $0.2\text{ mg/kg}$ rapid IV push (maximum second dose $12\text{ mg}$) if no response within 1–2 minutes.
   • Administration Technique: Rapid intravenous bolus via large-bore IV close to central circulation, followed immediately by a rapid $5\text{–}10\text{ mL}$ normal saline flush (two-syringe technique).

1. Rhythm: Symptomatic / Severe Sinus Bradycardia.
2. Contributing factors:
   • Hypoxia (most common cause in children)
   • Hypothermia
   • Hypovolemia / Shock
   • Hyperkalemia / Hypokalemia / Acidosis
   • Heart block / Cardiac pathology
   • Toxins / Drugs (e.g., digoxin, beta-blockers, organophosphates)
   • Increased intracranial pressure (Cushing's triad)
3. Emergency Interventions:
   • Maintain airway, support breathing with $100\%\text{ oxygen}$ and ventilation.
   • If $\text{HR} < 60\text{ bpm}$ with poor perfusion despite adequate oxygenation and ventilation $\rightarrow$ start Chest Compressions.
   • Epinephrine: $0.01\text{ mg/kg}$ ($0.1\text{ mL/kg}$ of 1:10,000) IV/IO every 3–5 min.
   • Atropine: $0.02\text{ mg/kg}$ (minimum $0.1\text{ mg}$, maximum single dose $0.5\text{ mg}$) if bradycardia is due to increased vagal tone, cholinergic drug toxicity, or primary AV block.
   • Consider transcutaneous pacing.

1. General Principles:

   • Do NOT perform blind finger sweeps (can push foreign body deeper into larynx).
   • If child is coughing effectively, encourage spontaneous coughing and observe closely.

2. Infant ($<1\text{ year old}$):

   • Conscious infant with severe obstruction (silent cough, cyanosis):
     • Position infant face-down (prone) along your forearm/thigh, supporting head with jaw.
     • Deliver 5 firm back slaps/blows between scapulae with heel of hand.
     • Turn infant face-up (supine) and deliver 5 chest thrusts (lower half of sternum, similar to CPR compressions).
     • Repeat cycle of 5 back blows and 5 chest thrusts until foreign body is expelled or infant becomes unresponsive.
   • Unresponsive infant:
     • Lower infant onto firm flat surface, call for emergency help.
     • Start CPR (30:2 single rescuer or 15:2 two rescuers). Look in mouth before ventilations; if foreign body is clearly visible, remove it.

3. Child ($\ge 1\text{ year old}$):

   • Conscious child:
     • Perform Heimlich maneuver (subdiaphragmatic abdominal thrusts): Stand behind child, place fist midline between xiphoid process and umbilicus, deliver quick upward and inward thrusts in sets of 5 until dislodged.
   • Unresponsive child:
     • Position supine, shout for help, initiate CPR (compressions $\rightarrow$ airway $\rightarrow$ breathing). Inspect oropharynx before each ventilation attempt.

1. Device: Laryngeal Mask Airway (LMA) / Supraglottic Airway Device (SAD).
2. Indications:
   • Rescue airway in "cannot intubate, cannot oxygenate / cannot ventilate" scenarios.
   • Elective airway management for short pediatric surgical procedures under general anesthesia.
   • Alternative airway during CPR when endotracheal intubation is difficult or unavailable.
3. Contraindications:
   • Complete upper airway obstruction below the level of the larynx.
   • Severe trismus or limited mouth opening.
4. Limitations:
   • Does not completely protect against gastric regurgitation and pulmonary aspiration.
   • May dislodge easily during patient transfer or resuscitation movements.
   • High airway pressures ($>20\text{ cmH}_2\text{O}$) can cause gastric insufflation and air leak.
5. Complications: Aspiration of gastric contents, laryngospasm, sore throat, local mucosal trauma, hypoglossal or lingual nerve neuropraxia.

1. Airway Maneuver: Modified Jaw-thrust without head tilt (while maintaining manual in-line cervical spine stabilization).
2. Spinal Cord Injury without Radiographic Abnormality (SCIWORA):
   • Yes, children have high vertebral elasticity compared to the spinal cord.
   • Definitive Diagnosis: MRI of the spine (demonstrates cord edema, contusion, hemorrhage, and ligamentous disruption).
3. Emergency Medical Treatment:
   • High-dose intravenous Methylprednisolone ($30\text{ mg/kg}$ IV bolus over 15 minutes, followed 45 minutes later by continuous infusion of $5.4\text{ mg/kg/hr}$ for 23 hours if started within 3–8 hours of injury).

1. Definitions (WHO consensus):
   • Drowning: The process of experiencing respiratory impairment from submersion/immersion in liquid resulting in death.
   • Non-fatal drowning: Survival (at least temporarily) following respiratory impairment from submersion/immersion.
2. Predisposing factors:
   • Seizure disorder (epilepsy)
   • Underlying cardiac channelopathy (Congenital Long QT Syndrome, e.g., Jervell and Lange-Nielsen / Romano-Ward syndrome)
   • Lack of adult supervision / inability to swim
   • Head/cervical trauma or intoxication (older adolescents)
3. Laboratory disturbances:
   • Electrolytes: Hyperkalemia (from hemolysis/acidosis/tissue hypoxia), Hyponatremia or Hypernatremia, Metabolic acidosis.
   • Hematological: Intravascular hemolysis, Disseminated Intravascular Coagulation (DIC).
4. CXR finding: Bilateral diffuse alveolar/interstitial pulmonary edema (ARDS / chemical pneumonitis).

1. Instrument: Uncuffed Endotracheal Tube (ETT).
2. Parts:
   • 15 mm machine connector/adaptor
   • Tube shaft with length depth markings (in cm)
   • Radiopaque longitudinal marker line
   • Vocal cord guide mark
   • Murphy's eye (side hole at distal bevel)
   • Distal beveled tip
3. Size calculation for 6-year-old child:
   • $\text{Uncuffed ETT Size (ID in mm)} = \frac{\text{Age in years}}{4} + 4 = \frac{6}{4} + 4 = 5.5\text{ mm}$ (always keep sizes 5.0 mm and 6.0 mm ready).
   • $\text{Cuffed ETT Size} = \frac{\text{Age}}{4} + 3.5 = 5.0\text{ mm}$.
   • Depth of insertion: $\text{Age}/2 + 12 = 3 + 12 = 15\text{ cm}$ (or $\text{ETT ID} \times 3 = 16.5\text{ cm}$).
4. Physiological changes during intubation:
   • Raised Intracranial Pressure (ICP) and Intraocular Pressure (IOP)
   • Reflex laryngospasm and bronchospasm
   • Hypoxia and hypercapnia if delayed
   • Hypertension and tachycardia in older children (sympathetic reflex)
   • Vagal-mediated bradycardia and hypotension in infants and young children

1. Device: Venturi Mask (Air-entrainment mask / Fixed-performance oxygen delivery system).
2. Significance: The color of each adaptor indicates the specific fixed fraction of inspired oxygen ($\text{FiO}_2$) delivered at a designated minimum oxygen flow rate.
3. Color-Coded Venturi Adaptors:
   • Blue: $24\%\text{ FiO}_2$ (at 2–4 L/min)
   • White: $28\%\text{ FiO}_2$ (at 4–6 L/min)
   • Yellow: $35\%\text{ FiO}_2$ (at 6–8 L/min)
   • Red: $40\%\text{ FiO}_2$ (at 8–10 L/min)
   • Green: $60\%\text{ FiO}_2$ (at 12–15 L/min)
4. Oxygen Delivery Systems:
   • a. Nasal Prongs: Flow 1–4 L/min $\rightarrow \text{FiO}_2 \approx 24\%\text{–}35\%$ (approx $4\%\text{ per L/min}$).
   • b. Simple Face Mask: Flow 6–10 L/min $\rightarrow \text{FiO}_2 \approx 35\%\text{–}60\%$.
   • c. Non-Rebreathing Mask (NRBM): Flow 10–15 L/min $\rightarrow \text{FiO}_2 \approx 85\%\text{–}95\%+$.

The 7 Ps of Rapid Sequence Intubation (RSI):

1. Preparation: Check suction, airway equipment (ETT, laryngoscopes, bag-mask), monitors, and prepare medications.
2. Preoxygenation: 100% $\text{O}_2$ via non-rebreather mask for 3–5 minutes to wash out nitrogen and create oxygen reservoir.
3. Pretreatment / Premedication:
   • Atropine ($0.02\text{ mg/kg}$, min $0.1\text{ mg}$) in infants $<1\text{ year}$ to prevent reflex bradycardia.
   • Lidocaine ($1.5\text{ mg/kg}$) in raised ICP.
   • Fentanyl ($1\text{–}2\text{ }\mu\text{g/kg}$) to attenuate sympathetic response.
4. Paralysis with Induction (Sedation):
   • Induction agents: Ketamine ($1\text{–}2\text{ mg/kg}$), Propofol ($1.5\text{–}2.5\text{ mg/kg}$), Etomidate ($0.3\text{ mg/kg}$), or Midazolam ($0.1\text{–}0.3\text{ mg/kg}$).
   • Neuromuscular blocking agents: Succinylcholine ($1.5\text{–}2\text{ mg/kg}$) or Rocuronium ($1\text{–}1.2\text{ mg/kg}$).
5. Protection and Positioning: Sniffing position (with shoulder roll in infants). Apply Sellick maneuver (cricoid pressure) if indicated.
6. Placement with Proof: Direct/video laryngoscopy, pass ETT through vocal cords. Confirm placement with continuous waveform capnography ($\text{ETCO}_2$), bilateral equal breath sounds, and absence of gastric insufflation.
7. Post-intubation Management: Secure ETT, note cm mark at lips, chest radiography for depth confirmation, mechanical ventilation, and continuous post-intubation sedation/analgesia.

1. Fluid Requirement Calculations:

   • First 24-Hour Resuscitation Fluid (Parkland Formula): $$\text{Volume} = 4\text{ mL} \times \text{Weight (kg)} \times \%\text{ Burn} = 4 \times 12 \times 45 = 2160\text{ mL of Ringer's Lactate}$$
     • First 8 hours from time of injury (5:30 AM to 1:30 PM): Half volume = $1080\text{ mL}$. (Since child arrived at 10:30 AM, 5 hours have already elapsed; remaining $1080\text{ mL}$ must be run over the next 3 hours by 1:30 PM).
     • Next 16 hours (1:30 PM to 5:30 AM next day): Remaining half volume = $1080\text{ mL}$ ($67.5\text{ mL/hr}$).
     • Plus Maintenance Fluid: $1100\text{ mL/24 hr}$ ($1000 + 2 \times 50$).
   • Second 24-Hour Fluid:
     • Colloid / 5% Dextrose in half-normal saline or RL at $\approx \frac{1}{2}$ of first day requirement ($1080\text{ mL}$) plus maintenance.

2. Completion Time: First 24-hour cycle is completed at 5:30 AM the next day (24 hours from the exact time of burn injury).

3. Desired Serum Albumin: $\ge 2.5\text{–}3.0\text{ g/dL}$ ($\ge 2.0\text{ g/dL}$ minimum).

4. Colloid (5% Albumin) Infusion:

   • For 30%–50% burns: $0.3\text{ mL}$ of 5% albumin/kg/% burn over 24 hours: $$\text{Dose} = 0.3 \times 12\text{ kg} \times 45 = 162\text{ mL of 5% Albumin}$$