Transcript No Slide Title

Pediatric Advanced
Life Support
PALS 2000
Major changes
Itai Shavit, MD
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International Guidelines Revision
Process: Science Review
• International evidence evaluation and
•
•
guidelines conferences
— More than 500 experts from more than 30
countries attended
— More than 25,000 manuscripts reviewed
Recommendations reviewed and revised by
science subcommittees, international editorial
board, and Circulation editorial board
Guidelines endorsed by 6 international
resuscitation councils
Class of Recommendation
Class I: Definitely recommended
(at least 1 prospective positive RCT)
Class II: Acceptable and useful
IIa: Good to very good evidence
(Multiple studies, “good methodology”, no harm)
IIb: Fair to good evidence
Indeterminate: Preliminary evidence needs
confirmation; no harm
Class III: Not acceptable, may be harmful
Class of recommendation reflects quality of
evidence and not clinical preference
BASIC LIFE SUPPORT
© 2001 American Heart Association
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Compression-Ventilation Ratios
• A compression-ventilation ratio of 15:2 is now
•
recommended for 1 or 2 rescuer CPR for older
children (>8 y/o) and adults until the airway is secure.
15:2 ratio provides more compressions per minute
and higher coronary artery perfusion pressure —
appropriate for primary cardiac arrest
Once the airway is secured, ventilations and
compressions may be asynchronous.
Coronary Perfusion Pressure Improves
With Sequential Compressions
CPP at 5:1 ratio
CPP at 15:2 ratio
Two Thumb–Encircling Hands Technique
Preferred for Infant 2-Rescuer CPR by HCP
Two Thumb–Encircling Hands Technique
Preferred for Infant 2-Rescuer CPR by HCP
• The 2 thumb-encircling hands technique is
preferred for chest compressions when 2rescuer CPR is performed by Health Care
Providers.
• This technique is not recommended for lay
rescuers or when chest compressions are done
by the lone health care provider.
AIRWAY
© 2001 American Heart Association
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Securing the airway
• Role of prehospital tracheal intubation
• Secondary confirmation of tracheal tube
placement strongly recommended
• Use of laryngeal mask airway acceptable
Laryngeal Mask Airway
•
The LMA can be used to
secure an airway in an
unresponsive/unconscious
patient
Use of Laryngeal Mask Airway in
Pediatric Advanced Life Support
• Extensive experience with pediatric and adult
patients in the operating room
• An acceptable alternative to intubation of the
unresponsive patient when the healthcare
provider is trained
• Contraindicated if gag reflex intact
• Limited data outside the operating room
(Class Indeterminate)
Secondary Confirmation of Tracheal Tube
Placement: Exhaled CO 2 in
Patients With a Perfusing Rhythm
• Normal exhaled CO2 should be approximately
equal to PaCO2 if airway is patent and
unobstructed
• Normal CO2 in esophagus is approximately zero
• Exhaled CO2 detected from tube is sensitive and
specific for tracheal tube placement if perfusing
rhythm is present in patient weighing >2 kg
Colorimetric Exhaled CO2 Detector
Yellow:
Exhaled CO2
detected
Purple:
No exhaled
CO2 detected
BREATHING
© 2001 American Heart Association
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Prehospital Tracheal Intubation vs
Bag-Mask Ventilation
• Bag-mask ventilation
•
may be as effective as
intubation if transport
time is short
Tracheal intubation
requires training and
experience
Prehospital Tracheal Intubation vs
Bag-Mask Ventilation
Effect of Out-of-Hospital Pediatric Endotracheal
Intubation on Survival and Neurological Outcome A
Controlled Clinical Trial
Marianne Gausche, MD; Roger J. Lewis, MD, PhD; Samuel
J. Stratton, MD, MPH; Bruce E. Haynes, MD; Carol S.
Gunter, BSN, MPA; Suzanne M. Goodrich, RN, MSN;
Pamela D. Poore, RN; Maureen D. McCollough, MD, MPH;
Deborah P. Henderson, PhD, RN; Franklin D. Pratt, MD;
James S. Seidel, MD, PhD
JAMA. 2000;283:783-790.
Prehospital Tracheal Intubation vs
Bag-Mask Ventilation
Compared the survival and neurological outcomes
of pediatric patients treated with bag-valve-mask
ventilation (BVM) with those of patients treated
with BVM followed by ETI (rapid transport EMS
system).
Controlled clinical trial , 1994-1997, 830 p, <12 y/o,
JAMA. 2000;283:783-790.
Prehospital Tracheal Intubation vs
Bag-Mask Ventilation
There was no significant difference in survival
between the BVM and ETI groups (30% vs. 26%) or
the rate of good neurological outcomes (23% vs.
20%).
JAMA. 2000;283:783-790.
CIRCULATION
© 2001 American Heart Association
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Intraosseous Needles Are Recommended
for Patients >6 Years of Age
• Access to circulation is critical.
“No one should die because of lack of
vascular access”
• Successful use of intraosseous needles has
been documented in older children and
adolescents
RHYTHM
DISTURBANCES
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Potentially Reversible
Causes of Arrest: 4 H’s
• Hypoxemia
• Hypovolemia
• Hypothermia
• Hyper-/hypokalemia and metabolic causes
(eg, hypoglycemia)
Potentially Reversible
Causes of Arrest: 4 T’s
• Tamponade
• Tension pneumothorax
• Toxins/poisons/drugs
• Thromboembolism (pulmonary)
Drug Therapy for Cardiac Arrest
• Epinephrine: the drug of choice
— Initial IV/IO dose: 0.01 mg/kg (tracheal: 0.1 mg/kg)
— High dose Adrenaline is De-emphasized. Routine
•
use of high doses of epinephrine is not
recommended but may be considered (IIb) for
conditions such as sepsis, anaphylaxis, or
b-blocker overdose
Vasopressin: a potent vasoconstrictor
— Adult clinical and animal cardiac arrest studies
support use in adult refractory VF arrest
— Asphyxial model: no benefit
— No data in pediatric cardiac arrest (Indeterminate)
Vagal Maneuvers for
Supraventricular Tachycardia
• Evidence supports use of vagal maneuvers to try to
•
•
terminate supraventricular tachycardia, particularly
in the stable patient (Class IIa)
Can be performed while preparing for drug
administration or cardioversion
Maneuvers:
— Apply ice water to the face of infants and young
children (Note: Do not occlude airway.)
— Older children may blow into occluded straw
Amiodarone
• Amiodarone can be used to treat both SVT and
VT/VF. In particular for refrartory VF (patient
not responds to 3 shocks, 1 dose of Adrenaline,
and a 4th shock (class indeterminate)
• Extrapolation from adult cardiac arrest and
pediatric nonarrest data suggest a role in
shock-resistant VF/pulseless VT
Amiodarone
Amiodarone for resuscitation after out-of-hospital
cardiac arrest due to ventricular fibrillation.
Kudenchuk PJ, Cobb LA, Copass MK, Cummins RO,
Doherty AM, Fahrenbruch CE, Hallstrom AP, Murray
WA, Olsufka M, Walsh T.
N Engl J Med. 1999 Sep 16; 341(12): 871-8
Amiodarone
In patients with out-of-hospital cardiac arrest due to
refractory ventricular arrhythmias, treatment with
amiodarone resulted in a higher rate of survival to
hospital admission. Whether this benefit extends to
survival to discharge from the hospital merits further
investigation.
N Engl J Med. 1999 Sep 16; 341(12): 871-8
Prehospital Use of AEDs for
children
“Shockable rhythms” in children
• Recent data suggests that pediatric
VF/pulseless VT at the pre-hospital setting is
more common than previously thought
• When VF/pulseless VT is present, early
defibrillation often improves survival
Percent survival
Effect of Time to Defibrillation on Survival
From Witnessed VF Cardiac Arrest
100
90
80
70
60
50
40
30
20
10
0
1 MIN
2 MIN
3 MIN
4 MIN
5 MIN
6 MIN
7 MIN
8 MIN
9 MIN 10 MIN
Cummins 1989
AHA new Recommendations (2003) for
Prehospital Use of AEDs in Victims 1-8
Years of Age
• At the time of publication of ILCOR
guidelines 2000, AEDs were not cleared by the
FDA for use in young children. Children < 8
with VF have been “orphans” for electrical
treatment at the pre-hospital setting.
• The new generation of AEDs are biphasic (less
energy is delivered), and sensitive for detection
of “shockable” rhythms in children and infants.
AHA new Recommendations
(2003) for Prehospital Use of AEDs
in Victims 1-8 Years of Age
• AEDs may now be used for children 1-8 y/o
who have no signs of circulation. Ideally the
device should deliver a pediatric dose.
• (the lone rescuer should always starts with 1 min
of CPR before activating EMS or using AED)
Post resuscitation
© 2001 American Heart Association
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Postresuscitation Interventions
• Provide normal oxygenation, ventilation
• Monitor temperature
— Treat/prevent hyperthermia
— Tolerate/don’t correct mild hypothermia
• Anticipate, treat myocardial dysfunction
• Maintain normoglycemia (avoid hyperglycemia
and hypoglycemia)