Transcript Strive to Survive: Improving Cardiac Resuscitation

Selected Pediatric Topics
Strive to Survive: Improving Cardiac Resuscitation
November 4,2016
Robert W. Hickey, M.D., FAAP, FAHA
Professor of Pediatrics
Professor of Clinical and Translational Science
Children’s Hospital of Pittsburgh of UPMC
University of Pittsburgh School of Medicine
Disclosures
• I have no relevant financial relationships to disclose
• Past Chair of AHA-Peds Committee and AHA-ECC
• Co-Chair of the 2010 International Guidelines
Conference
Learning Objectives
• Important changes to the Guidelines
• Impact of layperson CPR upon survival
• Importance of respirations in pediatric
CPR
• What to do after the arrest
Learning Objectives
• Important changes to the Guidelines
Review of new literature led to upgrading or
downgrading for some levels of evidence
BUT
the guidelines remain mostly unchanged
Emphasis remains on good CPR and CPR
training
Learning Objectives
• Impact of layperson CPR upon survival
Evidence Supporting Focus
on CPR
• CPR is important
• Not enough people get CPR
Focus on CPR
• CPR is Important
• Bystander CPR doubles survival of OOH
arrest (peds and adults) !!!!!!!!
Donoghue et al. Annals Emerg Med 2005;46:512-22
Collapse
Bystander CPR
ROSC
EMS CPR
Visible in Studies
ROSC = Return of
Spontaneous Circulation
Collapse
Bystander CPR
resulting in
ROSC = 41
All survived
EMS CPR=300
6 survived
Sirbaugh et al. Annals Emerg Med 1999;33:174-84
Collapse
Bystander CPR
EMS CPR=43
5 survived
ROSC
Selected pts=11
1 died
3 intubated
3 neuro consults
Hickey et al. Annals Emerg Med 1995;25:495-501
Importance of CPR
• Bystander CPR MORE THAN doubles
survival of OOH arrest (peds and adults)
Focus on CPR
Not enough people get CPR
• Only 1/3 of OOH cardiac arrest victims get
CPR prior to EMS arrival (peds and adults)
Donoghue et al. Annals Emerg Med 2005;46:512-22
Focus on CPR
Not enough people who get CPR, get
good CPR
• Too few chest compressions
• Chest compressions are too weak
• Too many ventilations
• Too many interruptions
Solutions
CC only CPR (CCC)?
Advantages
– Less fear of infectious disease
– Less complicated to teach and
perform
– Preserve CPP
– BUT, will it still work?
Lancet 2007;369:920-926
Kitamura et al Lancet 2010;375:1347-1354
Favorable Neurologic Outcome at 30 Days
In 1-17 yo
No
Bystander
CPR
CC
only
CC+V
All Pts
34/1632
(2.1%)
20/538
(3.7%)
39/906
(4.3%)
Cardiac
Cause
14/339
(4.1%)
14/158
(8.9%)
28/282
(9.9%)
1.2
(0.55-2.7)
NonCardiac
Cause
20/1293
(1.5%)
6/380
(1.6%)
45/624
(7.2%)
5.54
(2.5-17)
CC+V
vs
CC Only
Arterial Blood Gas
(after 7 min of CPR for VF)
SaO2
pCO2
pH
CC+RB
92±1*
25±2
7.49±.0
2
CC
76±6*
37±5
7.41±.0
3
* p<0.01 ROSC EQUAL
Berg, Circulation 1997
Arterial Blood Gas
(after 7 min of CPR-asphyxia)
SaO2
pCO2
pH
CC+RB
(15:2)
87±6**
45±8**
7.20±.02*
CC
17±5
97±5
7.01±.06
* p<0.001
ROSC BETTER with RB
Berg, Circulation 1997
So, why teach CCC CPR?
For every 100 resuscitations in
the out-of-hospital setting,
1.6 will include a child
Who should be taught CPR with
ventilations?
• Anyone likely to resuscitate
a child
• Life guards
• School teachers
• Baby sitters
Push Hard, Push Fast
Learning Objectives
• What to do after the arrest
After the arrest
•
•
•
•
•
Coroner
CORE
PCP
Death Certificate
Help with grieving
– Social workers
– Personal space
– Death packet (foot print; lock of hair, etc.)
• See the back-up of patients
• What else
After the arrest
• What else?
• ---be a detective (doctor)
– HPI
– PMH
– Fam Hx
– Review previous records (EKGs?)
Post-Mortem Work
N Engl J Med. 1999 Oct 7;341(15):1121-5.
Followed by case reports in SIDS, aborted SIDS, near drownings…
•
Case Report
– 19 yo woman
– Swimming laps in health club
found in 4 ft water
– ACLS in field
– QTc = 600 msec
– Died in ICU 12 h later
Ackerman et al NEJM 1999;341:1121-25
Molecular Diagnosis of the Inherited Long-QT Syndrome in a Woman
who Died After Near Drowning
•
Case Report
– Post-mortem section of myocardium
molecular genetic screening for mutations
known to cause long-QT syndrome
discovered a novel mutation (9-bp
deletion) in the KVLQT1 gene
– Similar case report in a 10 yo near-drowning
victim in Pediatrics 1999:101:306-308
– Schwartz et al ( NEJM 2000;343:262-267)
describe a sodium channel gene mutation in
an infant who nearly died of SIDS
Long QT syndrome (LQTS), short QT syndrome,
WPW, Brugada syndrome, catecholaminergic
polymorphic ventricular tachycardia (CPVT),
arrhythmogenic right ventricular
cardiomyopathy (ARVC)…
Three Questions
• How many patients with sudden,
unexpected death have a normal
autopsy ?
– How many of these patients will have a
channelopathy?
• Will a diagnosis of a channelopathy
in the proband identify other family
members at risk for sudden death?
Three Questions
• How many patients with sudden, unexpected
death will have a normal autopsy ?
– 14-35% (about 1/3rd)
Three Questions
• How many of these patients will have a
channelopathy?
– 2-10% SIDS
– 14-20% young adults
(2,500/yr) in USA
Three Questions
• Will a diagnosis of a channelopathy in
the proband identify other family
members at risk for sudden death?
– 22-35% of families
YOUR QUESTIONS
(screening questions for family
history of sudden death)
• Has anybody in the family died
unexpectedly
• Has anybody died before 50 yo
• Has anybody drowned
• Has anybody died in a car accident
• Is there a family history of seizures or
“spells”
A two-year-old boy presents to the ED after a
brief LOC. He has lost consciousness four
times over a period of five months. Three of the
episodes occurred when the child became
upset. These episodes had previously been
diagnosed as "breath-holding spells”.
Franklin WH, Hickey RW. Long QT syndrome. NEJM 1995; 333:355
Take Home Points
•
•
•
•
Guidelines are mostly unchanged
CPR is important
Not enough people get CPR (~1/3 of OOH)
Bystander CPR doubles survival from OOH
arrest
• Ventilations are important in pediatric CPR
• Be a detective after the arrest