Transcript Pediatric Resuscitation - Calgary Emergency Medicine

April 15, 2010
Hussein Unwala
Marc Francis
Objectives
 Case based
 Literature Review
 ACLS guidelines
 Numbers that will help you in a crunch
 Pediatric Airway
 IV access
 Controversies in resuscitation
Personal reading
 RSI dosing and drugs for pediatrics
 Inotropes and Pressors
 Detailed management of specific presentations
Challenges of Pediatric Resuscitation
 Emotional
 Lack of patient verbal skills
 Patient fear
 Varying normal values for vital signs
 IV access
 Drug dosing
 Technical skills more challenging
 Parental presence
 Prospective, population-based database from 2005 –
2007
 Incidence highest in infants

72.71/100 000 person years in infants, 3.73 in children, 6.37 in
adolescents vs 126.52 for adults
 Survival for all pediatric OHCA 6.4%

3.3% for infants, 9.1% of children, 8.9% for adolescents vs
4.5% for adults
Etiologies
Out-of-hospital
 Asphyxia (67%)
 SIDS
 Submersion
 Pulmonary Disease
 Ischemic (61%)
 Hypovolemia/Trauma
 Sepsis
 Myocardial Dysfn
 Arrythmogenic (10%)
 Vfib Vtach
In-hospital
 Sepsis
 Respiratory failure
 Hypotension
 Drug toxicity
 Metabolic disorders
 Arrhythmias
 Comprehensive review 1966 – 2004
 5363 pts in 41 different studies


12.1% survived to hospital discharge
4% survived neurologically intact
 Better outcomes with


Trauma arrest
Submersion injury
 Improved survival with


Witnessed arrest
Bystander CPR
 Prospective observational study from a registry
of cardiac arrests
 The rate of survival to hospital discharge
following pulseless cardiac arrest was higher in
children than adults:
27% (236/880) vs 18% (6485/36,902)
adjusted OR = 2.29, 95%CI (1.95-2.68)
 Of these survivors 65% of children and 73% of
adults had good neurological outcome
 Outcomes after initial (ARRYTHMOGENIC ARREST)v
tach/ v fib are “good” (35% survival),
 But outcomes after subsequent
(ASPHYXIAL/ISCHEMIC ARREST) v tach/ v fib are
worse (11% survival), even compared to initial
asystole/PEA (27% survival)
Generally, of survivors…
Airway intervention saves 90%
IV access saves 9%
Drugs save 1%
Case 1
 You are at your daughter’s soccer game enjoying a cold
one
 There is a large commotion on another pitch and they
call for help
 A 4yo M suddenly collapsed on the field and is not
breathing
 You rush to his side and find him to be apneic and
pulseless….
2005 ACLS
 Simplify resuscitation
training and improve
the effectiveness
2005 ACLS Key Points
 Push hard and fast

Chest compressions at rate of 100/min
 Limit interruptions in chest compressions
 Universal compression to ventilation ratio

30:2 for all lone rescuers
 Each breath should be delivered over 1 second
 Attempted defibrillation than immediate CPR
Compression:Ventilation Ratio
Single Provider
 Universally 30:2 for all
age groups for single
provider CPR except
neonates
2 Provider CPR
 30:2 for adult 2
providers
 15:2 for infants and
children two providers
 Continuous
compressions when
advanced airway in
place at 8-10 bpm
Pediatric Chest Compressions
 Rescuers may use 1 or 2 hands to give chest
compressions
 Children >1yo

press at the nipple line
 Infants <1yo



Press just below the nipple line
Use 2 fingers for compression in lone CPR
2 thumb encircling technique for 2-provider CPR
Pediatric Chest Compressions
 Compress the chest
1/3 – 1/2 its depth
 Change compression
provider every 2 mins
 Mannekin based study with 40 subjects
 Compressions at 100/min for 2 consecutive periods of
3mins with 30 seconds rest in between
 Number of satisfactory chest compressions performed
decreased progressively during resuscitation (p< 0.001)






First min = 82/min
Second min = 68/min
Third min = 52/min
Fourth min = 70/min
Fifth min = 44/min
Sixth = 27/min
 Effect was greater in female providers
 Providers did not perceive their own fatigue
 The Coach comes
over and says they
have an adult AED
inside the nearby
arena….
 Do you want to use
it?
AEDs in Children
 Recommended for children ≥ 1 year old
 In out of hospital arrest use the AED after 5 cycles of
CPR (~2 mins)
 If the available AED does not have child pads can use a
regular AED with adult pads
 Evidence is insufficient to recommend for or
against the use of AEDs in infants under 1 year of
age
 Class Indeterminate
Shock dose
 Biphasic or Monophasic
 Initial Shock dose is the same
 2J/kg initially
 4J/kg subsequent
Case 1 con’t
 The AED shows Asystole and no shock is delivered.
 Paramedics arrives on scene and 3 rounds of Epi with
good CPR are administered with no effect
 The Medic asks you if he should try high dose
epinephrine???
 Retrospective cohort study comparing high dose epi to
standard epi in OOHCA
 N= 65 pts <18yo
 40pts (62%) HDE
 13pts (20%) SDE
 Outcome measures





ROSC
Return of organized electrical activity
Hospital admission
Hospital discharge
Neuro outcomes
 HDE did not improve the rates of any of the outcomes
High dose Epinephrine
 High dose Epi = 0.1mg/kg IV/IO
 Routine use has never shown a survival benefit
 May be harmful particularly in asphyxia
 Currently is not recommended routinely
 Class III evidence
 Considered only in exceptional circumstances such as
B-blocker overdose
Case 2





13 month old Male. Attends daycare.
Diagnosed with “reactive airways” in the past
Mother has ventolin puffer he rarely uses
Runny nose and cough for 3 days
Then marked respiratory distress noted last 24hrs and
no po intake
 Taken to resuscitation room
Case 2
 Vitals
 T 38.2 °C
 HR 179
 RR 56
 BP 81/56
 Sat 88% on RA
 Chemstrip 4.6
 Even before you examine
the child….
 What is your impression
of the vital signs
Heart rate normals
>200 is abnormal in any age group
>180 is usually abnormal unless in the first
year of life
Normal resting RR
Newborn
Infant (1–6 months)
Infant (6-12 months)
1-4 yrs
4-6 yrs
6-12 yrs
>12 yrs
* >60 abnormal in all age groups
30-60
30-50
24-46
20-30
20-25
16-20
12-16
Estimate of Minimum Systolic BP
Age
0 – 1 month
1mth – 1year
1yr – 10yrs
>10yrs
Minimal Systolic BP
(lowest 5%)
60mmHg
70mmHg
70mmHg + 2 (age)
90mmHg
Less than 60mmHg is always abnormal
Hypotension:
Compensated
vs
decompensated
shock
LATE!
SUDDEN!
Case 2 Continued
 Generally:
 looks unwell, pale and in marked distress
 CVS:
 Tachy, normal HS, cap refill 4 secs, normal pulses
 Resp:
 Tachypneic, suprasternal and scalene retractions, silent
chest
 During next 5 mins patient becomes more drowsy
and lethargic with apneic periods
 What do you want to do now…..
Numbers that can help in a crunch…
 Estimate of weight:
= 8 + 2 (age)
 SBP lowest 5%
= 70 + 2 (age)
 Estimate of tube size:
= age / 4 + 4 uncuffed
= age/4 + 3 cuffed
 Depth of ETT insertion:
= ETT Size x 3
 Foley catheter size
= ETT size x2
 NG tube size
= ETT size x 2
 Chest Tube size
= ETT size x 4
What if you can’t remember doses
 Under stressful
situations your brain
turns to mush…
 You stink at math…
BROSELOW TAPE!!!!
 Examined 7500 kids in Ohio
 Compared actual weight to predicted weight by the
Broslow
 Broslow colour predicted by height vs actual weight
 Overall percentage agreement 66.2%
 Overall Kappa value was 0.61
 Accurately predicted ETT size in 71%
 Tape accurately predicted medication doses within
10% in 55-60% of patients
 Kids were under dosed (by ≥10%) 2.5 to 4.4 times
more often than those over dosed (by ≥10%) p<0.05
 Concluded that the Broselow tape inaccurately
predicts weight in up to 1/3 of North American kids
and could result in underresuscitation
 Prospective observational study comparing accuracy of
3 different weight estimation methods on US
population
 Concluded that Broselow tape and Leffler formula
accurately predicts weights < 40kg, but the Theron
formula performs better at weights > 40kg
 A decision is made
that the patient
requires intubation
 What are the issues
in intubating a child?
Differences in Peds Airway
1) Big tongue and more soft tissues
2) Narrowest point at subglottis
3) Anterior/cephalad larynx
4) Short trachea
5) Prominent occiput
6) Big floppy epiglottis
7) Higher metabolic rate
8) Lower FRC
9) More compliant chest wall
10) Smaller airway caliber
Anatomical Differences in Peds Airway
To cuff or not to cuff….that is the question
 Cuffed endotracheal tubes may be used in infants
(except newborns) and children in in-hospital
settings provided that cuff inflation pressure is
kept <20 cm H2O
 One randomized controlled trial 3 prospective
cohort studies and 1 cohort study document no
greater risk of complications in children < 8yo

Khine HH, Corddry DH, Kettrick RG, et al. Comparison of cuffed and
uncuffed endotracheal tubes in young children during general
anesthesia. Anesthesiology. 1997;86:627–631
Case 3
 3yo M
 Sucking on large jaw breaker candy and onset of




choking
EMS called and currently on-route to ACH
Initially coughing and wheezing
2 mins out patch saying has become cyanotic, silent
and apneic
Unresponsive and weak pulse on arrival….
Airway Obstruction
 Signs of severe airway
obstruction
 Poor air exchange
 Children ≥ 1yo
 Abdominal thrust
 Increased breathing
difficulty
 Silent cough
 Cyanosis
 Inability to speak or
breath
 Infants ≤ 1yo
 Back slaps
 Chest thrust
Airway Obstruction
 Under 1yo risk of organ damage with abdominal
thrusts
 Give 5 back blows alternating with 5 chest thrusts
 Until relief or unresponsive
Airway Obstruction
 Your Abdominal blows are unsuccessful
 Other options???
 McGill Forceps
 R mainstem intubation of FB
 Surgical airway
Pediatric Surgical Airway
 Cricothyroidotomy
 Extremely difficult in kids <10yo (Almost impossible)
 Too small an anatomical space for Seldinger kit
 Often Cricoid cartilage is the narrowest portion so does
not bypass the obstruction
Pediatric Surgical Airway
 Transtracheal jet ventilation
 10 gauge needle or 14 gauge angiocath
 Standard wall source of O2
 Placed at the cricothyroid membrane or between the
tracheal rings inferior to the cricoid cartilage
 3cc Syringe with plunger removed and a 90° angle piece
connected to an ambibag for kids <5yo
 Pressurized Jet Ventilator for kids >5yo
Case 3 Continued
 You successfully transtracheal ventilate the patient
below the obstruction and get good chest rise and
return of Oxygenation
 The patient remains in PEA…
Case 4
 14yo healthy Male
 Motorcycle at 70km/hr hit the back of a stationary
truck
 Wearing Helmet
 Initially unconscious on scene and blood in airway
 EMS arrival has agonal respirations and then stops
breathing….
Case 4
 On STARS arrival patient receiving CPR and BVM
ventilation
 PEA on the monitor
 Obvious facial trauma and bilateral UE fractures
 Distended abdomen with periumbilical bruising
Case 4
 Bilateral needle decompression performed
 Successful crash ETT placed
 Attempts x 2 by STARS medical crew for IV line
with no success
 Monitor continues to show organized electrical
activity but pulseless….
IV access in Peds
 Few things cause more distress to non-pediatric
trained resuscitators
 Infants have small veins and often lots of SC tissues
 Even more difficult in the sick child or infant who is
hypovolemic and peripherally shut down
Vascular Access
 Peripheral IV




Technically easy
Difficult in small children
Peripherally shut down
Rate limited flow
 Central line



Technically challenging and time consuming
Femoral, Internal jugular, Subclavian
Larger bore
 Interosseous (IO)
The secret vein only anesthesia seems to
know about…
 Great Saphenous
Vein at the foot
 Consistently found
just anterior to the
medial malleolus
 May not be visible at
surface
 Large vein which is
easily cannulated
Interosseous
 Useful in all ages
 Previous recommendation was
after 90 seconds of attempts for
PIV
 Now recommendation is
immediately
 Allows for



Fluids
Drugs
Bloodwork
 Technically easy
 Complications
 Compartment
 Infection
ETT drug administration
 Administration of drugs into the trachea results in
lower blood concentration than the same dose
given by IV/IO route
 Recent animal studies
 Show that the lower epinephrine concentrations
achieved when the drug is delivered by the endotracheal
route may produce transient β-adrenergic effects.
 These effects can be detrimental, causing hypotension,
lower coronary artery perfusion pressure and flow, and
reduced potential for ROSC
Case 4 continued
 You get an IO running and after fluid resuscitation
with 1 liter of NS and 1 round or Epi you get a pulse
back
 The patient is transported to the ACH and remains
comatose
 The ICU resident asks you if you think we should cool
the patient???
Hypothermia ACLS
 Induced hypothermia may be considered if the
child remains comatose after resuscitation
 32ºC to 34ºC for 12 to 24 hours
 Class IIb Evidence
 Extrapolated from Adult data
 The 2005 guidelines emphasize the importance
of avoiding hyperthermia
 Providers should monitor temperature and
treat fever aggressively
 Class IIb Evidence
Case 5
 4yo M 15kg
 Known prior allergy
to bee stings
 Stung today at school
 Mother has Epi pen
in a drawer at home
 EMS arrives with him
at the ACH…
Exam
 Markedly swollen
face and eyes
 Lips and uvula
swollen
 Stridor noted
 Diffuse wheeze
 BP 70/51
 What would you like
to do?
Epi dosing in pediatrics
 Dose is always 0.01mg/kg
 In Anaphylaxis use 1:1000
epinephrine IM
 This is 1mg/ml =
0.01ml/kg IM



10kg = 0.1ml
20kg = 0.2ml
30kg = 0.3ml
 In Resuscitation use
1:10,000 epinephrine
IV/IO
 This is 0.1mg/ml =
0.1ml/kg IV/IO



10kg = 1ml
20kg = 2ml
30kg = 3ml
Case 6
 8 month old male
 Found unresponsive and blue by parents at 0600
in the morning
 EMS called and patch in indicating they are 5 mins
out with Asystole on the monitor and doing CPR
 Unable to get IV access
 You are preparing the trauma room and the team
for arrival of the patient….
Case 6
 Patient arrives in asystole with no signs of life
 The nurse gets an IV line and you administer
Epinephrine and Atropine IV followed by 1 minute of
good CPR
 There is no response…
 What now?
When to quit?
 Prospective study of 300 kids in CPA

No survivor received epinephrine
Sirbaugh et al. Annals of Emerg Med 1999. 33(174)
 101 kids with CPA or resp arrest

No survivors needed resuscitative efforts for more than 20
minutes or > 2 doses of epinephrine
Schindler et al. New Eng J Med 1996. 335(1473-79)
Termination of efforts
 Multiple other studies
 Small sample sizes, heterogeneous populations,
retrospective designs, etc
 Some survival despite prolonged resuscitation
 Difficult to draw any firm conclusions
 Very little consensus in the literature to guide you
 PEA and Asystole may not carry the same
prognosis in peds as it does in adults
Current ACLS guidelines
 If a child fails to respond to two doses of
epinephrine with a ROSC the child is unlikely to
survive
 Resuscitative efforts may be ceased in pediatric
CPA victims after 30 minutes unless exceptional
circumstances exist
i.e.



primary hypothermic insult
toxic drug exposure
recurrent or refractory VF/VT
 Cross sectional
survey
 160 PEM (70%)
 127 GEM (62%)
 PEM were >2x more
likely to terminate
resuscitative efforts if
ROSC was not
achieved by 25 mins
Case 6
 You administer a 2nd round of epinephrine with no
effect and then ask if anyone has any other
suggestions
 After 20mins of efforts you call the resuscitation
and note the time of death
 The family members who have been present
during the resuscitation are screaming for you to
try and do something else
 They want to take the baby to another hospital
hoping that they will be able to try something….
Family Presence during resuscitaiton
 Traditionally family members were excluded
 The concept of family-centered care in the ED has
now become more widespread
 Overwhelmingly family members are in favour or
being present
 ED staff opinion has been mixed
 Many organizations now endorse family presence

Systematic Review of the literature
Conclusions:
1)
2)
3)
4)
5)
6)
7)
8)
When given the option, Families tend to prefer to be present
In retrospect, most parents do not regret their decision to be
present
Clinician opinion varies on whether parents should be
present
Parents did not generally interfere with their child’s care and
serious parental interference was not reported
All members of the resuscitation team must be in
agreement
Dedicated medical facilitator should accompany the patient
Institutions should have guidelines, though most do not
Trainees should be provided with skills and experience in
functioning under parental presence
Pediatric Death in ED
 No formal training in coping with pediatric deaths
 With ED death there is usually no established
relationship with the parents
 Viewed as particularly tragic with strong emotions
 Children aren't supposed to die
 It's not natural
 The child never had an opportunity to experience a full
life
Pediatric Death in ED
CRISIS
 Powerful and often
uncontrollable emotions
 Illogical or impaired
decision-making abilities
 Recruiting other team
members and family
members for support
GRIEF
 Begins with understanding
that the child's death is
real
 Allow (not force) family
members to see or hold
their dead child
 Prepare them for what they
may see
 Opportunity to take a
momento
Pediatric Death in ED
 Address family feelings of guilt


Reassure families that they did not contribute (either by acts of
commission or omission) to the child's death
Reassure families that every care procedure that could have been
implemented in the ED was implemented is important
 Health team debriefing
 Strengths and weaknesses of the resuscitation
 Each team member can have an opportunity to ask
questions or offer comments
Case . . .
 You are called to the trauma room. A mother is about
to deliver her newborn at 32 weeks gestation and your
colleague is asking you to resuscitate the baby.
 How do you prepare??
Initial Steps . . .
 Provide warmth under radiant heater
 Position head to open airway
 Clear airway with bulb syringe/suction
 Stimulate breathing
“Dry-exposed” Resuscitation
Gestational
Age > 28w
“Wet-in-bag” Resuscitation
Gestational
Age < 28w
“Wet-in-bag” Resuscitation

Polyethylene bags
significantly reduce the risk
of hypothermia in infants
<28 weeks on admission to
NICU

RR 0.63 (C.I. 0.42-0.93)
NNT 4

Resuscitation when meconium present
Case . . .
 The baby is delivered, and brought to the warmer. No
evidence of meconium is present. The baby is gasping
and cyanotic.
 Now what??
NRP algorithm
Routine
Care
Wait 30 seconds
Normal transition
Slide courtesy of ACoRN 2006
Rabi Y, Yee W, Chen SY, Singhal N.
J Pediatrics 2006 148( 5):590-594
ACoRN © 2006
 After 30 seconds of drying, suctioning the
nasopharynx, and positioning under the warmer,
respirations are still irregular. A palpated heart rate is
80
Can be done with room air, but if no appreciable improvement, add O2
If still no response???
0.01-0.03 mg/kg 1:10000
10 ml/kg NS via UVC
Withholding/Withdrawing
Resuscitation
 Reasonable to withhold resuscitation in scenarios
associated almost certainly with death (Class IIa)
 Extreme Prematurity (< 23 weeks), anencephaly, trisomy
13
 After 10 minutes of continuous and adequate
resuscitative efforts, discontinuation of
resuscitation may be justified if there are no signs
of life (Class IIb)