Transcript Paediatric Resuscitation - Calgary Emergency Medicine

Paediatric
Resuscitation
November 2001
contents
epidemiology
eitiologies of arrest – focus on difference
between adult and paediatric
ABC’s of peds resuscitation

airway (RSI, LMA’s, etc)
neonatal resuscitation - brief
pediatric cardiac rhythm disturbances
cardioversion/defibrillation/pacing
post recovery care/termination of efforts
age definitions
newly born – first hours of life
neonate – first month
infant – neonate to 1 year
child – 1yr – 8yrs
adolescent - >8 yrs
epidemiology
CPR is provided for only approximately
30% of out-of-hospital pediatric arrests.
survival after cardiac arrest in children
averages 7% to 11%

most survivors neurologically impaired
SIDS – 0.8/1000 births
eitiology
cause of arrest depends upon



age
location – ie. out-of-hospital vs. in-hospital
pre-existing illness
out-of hospital

trauma, SIDS, drowning, poisoning, choking,
severe asthma, and pneumonia
in-hospital

sepsis, respiratory failure, drug toxicity, metabolic
disorders, and arrhythmias
eitiology
much less likely primarily cardiac
in general…

progression from hypoxia and hypercarbia
(respiratory failure) OR shock  respiratory arrest
and bradycardia  asystolic cardiac arrest
therefore – ventilation (CPR) priority over
defib (vs. adults)
recognize early respiratory failure and shock
prevent arrest
eitiology
what about cardiac?
witnessed Sudden collapse
 arrythmias

prior hx cardiac disease
 congenital prolonged QT
 hypertrophic cardiomyopathy
 drug overdose

defib priority in these cases
airway
chin-lift/jaw thrust
oropharyngeal

Size? central incisor to angle jaw
nasopharyngeal

caution re: secretions, adenoids (difficult
insertion or external compression)
laryngeal masks
intubation
LMA
Zideman D - Ann Emerg Med - 01-Apr-2001; 37(4 Suppl): S126-36
not studied in infant/child resuscitation
complications more frequent in peds
correct size

1 = smallest; 3-4 = adult female; 4-5 = adult male
may be dislodged during transport/CPR
aspiration – little protection
Gandini D. Neonatal resuscitation with the laryngeal mask airway in
normal and low birth weight infants. Anesth Analg. 1999;89:6423

case series published in neonates – no patient
outcomes
intubation
Gerardi MJ. Rapid-sequence intubation of the pediatric patient.
Pediatric Emergency Medicine Committee of the American College of
Emergency Physicians. Ann Emerg Med - 1996 Jul; 28(1): 55-74
pediatric airway differences
larger head and occiput neck flexion and airway
obstruction when the child is supine
relatively larger tongue = less oral space
decreased muscle tone = passive airway obstruction
by the tongue
epiglottis shorter, narrower, more horizontal, and
softer
larynx anterior  visualization of the cords difficult
trachea is shorter  risk of right main stem intubation
airway is narrower = increased airway resistance
cricoid ring is the narrowest portion of the airway
RSI
preoxygenation
Basal oxygen use per kilogram per
minute in children is greater than that in
adults, predisposing the child to a
shorter interval before desaturation
30 seconds – 4 minutes
premedication
bradycardia



hypoxia
laryngoscopy (vagal)
meds: sux
atropine indications



<1 yo
1-5 yo receiving sux
Adolescents receiving 2nd dose sux
dose: 0.02mg/kg (minimum 0.1mg ; max
1mg)

1-2 minutes prior to intubaton
premedication
defasciculation recommended for >5yo

assumption that these patients are at greater risk
of the complications of fasciculations because of
their larger muscle mass
defasciculation not recommended for <5yo

complications of asystole and bradycardia with
succinylcholine
sedation
thiopental – can induce bronchospasm
(relatively contraindicated in asthmatics)
infants/neonates – more sensitive to
fentanyl
fentanyl may increase ICP in children
TABLE 3 -- Suggested sedatives for selected clinical situations.
Clinical Scenario
Normotensive/euvolemic
Options
Thiopental, midazolam, propofol
Mild hypotension/hypovolemia with
head injury
Mild hypotension without head injury
Thiopental, etomidate, midazolam
Severe hypotension
Ketamine, etomidate, ½ dose
midazolam
Ketamine, midazolam, propofol
Status asthmaticus
Status epilepticus
Isolated head injury
Combative patient
Ketamine, etomidate, midazolam
Thiopental, midazolam, propofol
Thiopental, propofol, etomidate
Midazolam, propofol, thiopental
paralysis - sux
avoid 2nd dose of sux

infants/children exquisitely sensitive  intractable
brady/arrest
recognize limitations to use of sux

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
hyperkallemia
be aware of possibility of undiagnosed
neuro/muscular dz’s
cholinesterase deficiency - 1 in 500 patients
MH - 1 in 15,000
ICP/IOP
not recommended for non-emergencies
paralysis – rocuronium
infants and children
0.6mg/kg paralysis in 60 seconds
 0.8mg/kg paralysis in 28 seconds

recovery 25% twitch
<10 months old – 45 minutes
 5 years old – 27 minutes

reversal agents
NB. be aware of myopathy with steriods
failed intubation
BMV with sellick maneuover
LMA
lighted stylet
retrograde
cricothyroidodomy not recomm. age <8
 complication rate 10-40%
 ? Seldinger technique safer ?
transtracheal jet ventilation
 surgical method of choice in emergency
 allows ventilation for 45-60 mins
 risk – aspiration, subcutaneous emphysema, barotrauma,
bleeding, catheter dislodgment, CO2 retention
intubation
Miller blade or Mac in older
tube size 4 + age/4
attempts should not exceed 30 seconds


bradycardia (<60)
hypoxia
depth of insertion (cm)


tube ID (in mm) x 3.
in children >2 years of age


depth of insertion (cm) = (age in years/2)+12.
direct visualization or breslow
confirm placement – end tidal CO2 etc
relative
contraindications
evaluated as difficult intubation/difficult
ventilation
major facial or laryngeal trauma
upper airway obstruction
distorted facial/airway anatomy
caution in patients who are dependent on
their own upper-airway muscle tone or
specific positioning to maintain the patency of
their airway

paralysis  lose that tone/positioning
intubation in prehospital setting
Gauche et al. A prospective randomized study of
the effect of out-of-hospital pediatric endotracheal
intubation on survival and neurological outcome.
JAMA. 2000;283:783–790.
endotracheal intubation may not improve
survival over bag-mask ventilation in all
EMS systems
endotracheal intubation appears to result in
increased airway complications
breathing
signs of respiratory failure/impending arrest
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increased respiratory rate
distress/increased respiratory effort
inadequate respiratory rate, effort, or chest
excursion
diminished breath sounds
gasping or grunting respirations
decreased level of consciousness or response to
pain
poor skeletal muscle tone
cyanosis
circulation
signs of circulatory comprimise

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
heart rate – tachycardia or bradycardia (prearrest)
presence and volume (strength) of peripheral
pulses
adequacy of end-organ perfusion

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mental status
capillary refill
skin temperature
urine output (>1cc/kg infant/child; >30cc/hr adolescent)
metabolic acidosis on laboratory evaluation
circulation
hypotension definitions
•
•
•
•
term neonates (0 to 28 days of age), SBP <60 mm
Hg
infants from 1 month to 12 months, SBP <70 mm
Hg
children >1 year to 10 years, SBP <70+(2xage in
years)
heyond 10 years, SBP <90 mm Hg
NB. remember – hypotension is late finding in
shock suggesting impending arrest
CPR
chest compressions with backboard

two handed in infants
internal cardiac massage not
recommended

chest wall compliance
vascular access
peripheral
interosseous


anterior tibial bone
distal femur, medial malleolus, ASIS, ?ulna/radius
central vein (femoral, ext/int jugular)


femoral prefered
catheter length

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Infants – 5cm
“young” child – 8 cm
“older” child – 12 cm
intra-tracheal – “LEAN” drugs (lipid soluable)
interosseous
all drugs, fluids ok
may need increased pressure of infusion

?increased risk fat emboli
can draw bloodwork

caution with bicarb infusion and interpreting MVO2
complications: fracture,compartment
syndrome, osteomyelitis, extravasation
fluids
NS, LR
blood

refractory shock to 40-60cc/kg crystalloid
no evidence for colloid or HTS
neonatal resuscitation
infrequent event in ER
preparation
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anticipate problems
get help
O2 source/BVM/intubation supplies
(laryngoscope/ET tube/suction adapter)
suction catheter
warmer/dry warm linen
medications
neonatal resuscitation
steps
1. under warmer
2. suction trachea if meconium
3. dry
4. remove wet linen
5. position
6. suction mouth then nose
7. tactile stimulation
neonatal resuscitation
1. evaluate respiration


none/gasping  PPV 15-30seconds  HR
spontaneous  HR
2. evaluate HR

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<60  PPV, CP
60-100 not increasing  PPV, CP if HR<80
60-100 increasing  PPV
>100  observe for spontaneous resp
3. HR after 30s <80  initiate meds
4. evaluate color  blue?  supplemental
O2
meconium
10-20% of all deliveries
intervention only with thick, particulate
stained amniotic fluid
suction when head delivered and on warmer

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10 french suction catheter; 100 mm Hg
Depth mouth to ear
direct visualization of glottis and suction
below cords

ET tube with suction adapter
rhythm disturbances
most often consequence not cause of
arrest

correct underlying causes
most asystolic or brady arrest
10-20% pulseless VT/VF

Proportion increases with age
bradyarrhythmias
eitiologies

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
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hypoxemia, hypothermia, acidosis, hypotension,
and hypoglycemia
vagal stimulation (intubation, suctioning)
CNS/ICP
toxicology
significant if



hemodynamic instability
<60 bpm
rapid decrease in HR despite oxgenation, vent,
perf
bradyarrhythmias
treatment

epinephrine for hypotension/poor perfusion

primarily treatment of choice
atropine for vagal mediated, heart blk
 pacing for heart blk


refractory?  epi or dopamine infusion
transcutaneous pacing
< 15kg  paediatric electrodes
> 15kg  adult
positioning
anterior (+) – posterior (-)
 R infraclavicular (+) – L midaxillary 4th ICS
(+)

PEA
often represents a preterminal condition
that immediately precedes asystole
frequently represents the final organized
electrical state of a severely hypoxic,
acidotic myocardium
PEA
hypovolemia
hypoxemia
hypothermia
hyperkalemia
tension pneumothorax
pericardial tamponade
toxins
pulmonary thromboembolus
PEA
oxygenate
ventilate
CPR
fluid resuscitate
epinephrine
special interventions
tachycardia
narrow complex
SVT – most common arrythmia
 sinus tachycardia

wide complex
abberancy – uncommon
 VT/VF

SVT vs sinus
tachycardia
Sinus tachycardia
SVT

most often narrow




abberent conduction
uncommon
HR >220
HR >180
abrupt onset/offset

narrow complex

HR < 220 infants
HR <180 children
aariable/slow
onset/offset
look for cause
(hypovolemia, fever,
etc)

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
SVT - options
unstable? cardioversion 0.5-1.0 J/kg
vagal maneuvers
adenosine 0.1 mg/kg – repeat 0.2 mg/kg
avoid verapamil in infants

refractory hypotension and cardiac arrest
verapamil in children (>1yr) – 0.1mg/kg
amiodarone
procainamide
ventricular arrhythmias
– VT/VF
uncommon in children
eitiology
congenital heart dz, cardiomyopathy,
myocarditis
 reversable causes

metabolic (hyperK,hyperMg, hypoCa, hypoglyc)
 drug toxicity
 hypothermia

VT
stable – options
amiodarone - 5 mg/kg over 20 to 60
minutes
 procainamide - 15 mg/kg over 30 to 60
minutes
 lidocaine - 1 mg/kg over 2 to 4 minutes


followed by 20 to 50 µg/kg per minute
unstable

cardioversion – 2-4 J/kg
pulseless VT/VF
defibrillation – 2-4J/kg
ventilation, oxygenation, fluid resusc
epinephrine
shocks
shock resistant (ie. >4)?

amiodarone 5mg/kg (max 15mg/kg/day)
cardioversion/defibrillati
on
paddle size


>1yr >10kg  adult paddles/pads
<1yr <10kg  infant paddles/pads
placement



both anterior (right upper/apex)
anterior-posterior
paddles/pads/gel should not touch each other
cardioversion/defibrillati
on
cardioversion 0.5j/kg, 1j/kg, 2j/kg
defib <8yo = 2 j/kg, 4 j/kg, 4 j/kg
defib >8yo, > 50kg = 200, 300, 360
AED’s > 8yo
?biphasic - >8yo >25kg
pharmacology epinephrine
epinephrine
0.01mg/kg (1:10 000) q3-5 min during
arrest
 0.1mg/kg (1:1000) intratracheal


0.1-0.2mg/kg (1:1000) “high dose” not
recommended
pharmacology - atropine
atropine
0.02 mg/kg
 minimum 0.1 mg – < paradoxical brady
 max 0.5mg in child x2 ; 1mg in adolescent
x2

pharmacology –
vasopressin
Vasopressin

systemic vasoconstriction



selective vasoconstriction of skin, skeletal muscle,
intestine, and fat
relatively less vasoconstriction of coronary, cerebral, and
renal vascular beds
reabsorption of water in the renal tubule
Not studied in paediatric arrest – not
recommended
pharmacology - calcium
calcium chloride
0.2 mL/kg of 10% calcium chloride
 slow infusion 20secs in arrest; 10 mins in
perfusing rhythm

indications
hypocalcemia
 hypermagnesemia
 ?PEA ?asystole – not recommended

pharmacology magnesium
25-50 mg/kg
indications

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
torsades
hypomagnesemia
severe asthma (refractory to bronchodilator x3)


Gurkan F. Intravenous magnesium sulphate in the
management of moderate to severe acute asthmatic children
nonresponding to conventional therapy. Eur J Emerg Med.
1999;6:201–205
Ciarallo L. Intravenous magnesium therapy for moderate to
severe pediatric asthma: results of a randomized, placebocontrolled trial. J Pediatr. 1996;129:809–814
pharmacology - glucose
infants
high glucose requirements
 low glycogen stores
 prone to hypoglycemia during stress

monitor glucose frequently
0.5 to 1.0 g/kg (10% or 25%)
or change to D5 or D10 containing
solutions post-resuscitation
pharmacology- sodium
bicarb
1 Meq/kg


1 ml/kg 8.4% solution
2 ml/kg 4.2% solution for infants (decr. osm load)
1st ventilation, oxygenation, perfusion
NB. again, most arrest respiratory – therefore
NaHCO3 could exacerbate
indications


hyperK, hyperMg, TCA, Na+ blking agents
?metabolic acidosis ?prolonged arrest
pharmacology naloxone
neonatal resuscitation
in mother whom received narcotics
during delivery
dose : 0.1 mg/kg IM/IV/SC/ET
post-resuscitation care
continued support of ABC’s
intensive monitoring

including frequent glucose, temperature
preserve brain function
avoid secondary organ injury
seek and correct the cause of illness
tertiary-care setting
airway/breathing
RR


Infants: 20-30
Children: 12-20
TV

7-10 cc/kg
peak pressures

20-25 cmH2O
PEEP 2-5 cm H2O
adjust to blood gases - PCO2 35
circulation
ongoing fluid resuscitation
inotropes/vasopressors/vasodilators
initially, may be unclear – intensive monitoring
environment
shock



hypovolemic
cardiogenic
septic – in children response may be decreased
myocardial function in sepsis (mixed picture)
termination of
resuscitation
in general, 30 minutes
absence of hypothermia, toxic drug
overdose
NB. ?family present during
resuscitation?