Paediatric Resuscitation

November 2001

contents

epidemiologyeitiologies of arrest – focus on difference between adult and paediatricABC’s of peds resuscitation airway (RSI, LMA’s, etc)

neonatal resuscitation - briefpediatric cardiac rhythm disturbancescardioversion/defibrillation/pacingpost 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 collapsearrythmias

prior hx cardiac diseasecongenital prolonged QThypertrophic cardiomyopathydrug overdose

defib priority in these cases

airway

chin-lift/jaw thrustoropharyngealSize? central incisor to angle jaw

nasopharyngealcaution re: secretions, adenoids (difficult

insertion or external compression)

laryngeal masksintubation

LMA

Zideman D - Ann Emerg Med - 01-Apr-2001; 37(4 Suppl): S126-36 not studied in infant/child resuscitationcomplications more frequent in pedscorrect size 1 = smallest; 3-4 = adult female; 4-5 = adult male

may be dislodged during transport/CPRaspiration – little protection

Gandini D. Neonatal resuscitation with the laryngeal mask airway in normal and low birth weight infants. Anesth Analg. 1999;89:642-3 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 supinerelatively larger tongue = less oral spacedecreased muscle tone = passive airway obstruction by the tongueepiglottis shorter, narrower, more horizontal, and softerlarynx anterior visualization of the cords difficulttrachea is shorter risk of right main stem intubationairway is narrower = increased airway resistancecricoid 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 Options

Normotensive/euvolemic Thiopental, midazolam, propofol

Mild hypotension/hypovolemia with head injury

Thiopental, etomidate, midazolam

Mild hypotension without head injury Ketamine, etomidate, midazolam

Severe hypotension Ketamine, etomidate, ½ dose midazolam

Status asthmaticus Ketamine, midazolam, propofol

Status epilepticus Thiopental, midazolam, propofol

Isolated head injury Thiopental, propofol, etomidate

Combative patient Midazolam, propofol, thiopental

paralysis - sux

avoid 2nd dose of sux infants/children exquisitely sensitive intractable

brady/arrest

recognize limitations to use of sux 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 children0.6mg/kg paralysis in 60 seconds0.8mg/kg paralysis in 28 seconds

recovery 25% twitch<10 months old – 45 minutes5 years old – 27 minutes

reversal agents NB. be aware of myopathy with steriods

failed intubation

BMV with sellick maneuoverLMAlighted styletretrogradecricothyroidodomy 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 oldertube size 4 + age/4attempts 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 ventilationmajor facial or laryngeal traumaupper airway obstructiondistorted facial/airway anatomycaution 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 pre-hospital 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 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 heart rate – tachycardia or bradycardia (pre-arrest) presence and volume (strength) of peripheral

pulses adequacy of end-organ perfusion

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 recommendedchest wall compliance

vascular access

peripheralinterosseous anterior tibial bone distal femur, medial malleolus, ASIS, ?ulna/radius

central vein (femoral, ext/int jugular) femoral prefered catheter length

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 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 <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 meds4. evaluate color blue? supplemental O2

meconium

10-20% of all deliveriesintervention only with thick, particulate stained amniotic fluidsuction when head delivered and on warmer 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 arrestcorrect underlying causes

most asystolic or brady arrest

10-20% pulseless VT/VFProportion increases with age

bradyarrhythmias

eitiologies 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

treatmentepinephrine for hypotension/poor perfusion

primarily treatment of choice

atropine for vagal mediated, heart blkpacing for heart blk

refractory? epi or dopamine infusion

transcutaneous pacing

< 15kg paediatric electrodes

> 15kg adult

positioninganterior (+) – 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 complexSVT – most common arrythmiasinus tachycardia

wide complexabberancy – uncommonVT/VF

SVT vs sinus tachycardia

SVT most often narrow

abberent conduction uncommon

HR >220 HR >180 abrupt onset/offset

Sinus tachycardia narrow complex

HR < 220 infants HR <180 children aariable/slow

onset/offset look for cause

(hypovolemia, fever, etc)

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

eitiologycongenital heart dz, cardiomyopathy,

myocarditis reversable causes

metabolic (hyperK,hyperMg, hypoCa, hypoglyc)drug toxicityhypothermia

VT

stable – optionsamiodarone - 5 mg/kg over 20 to 60

minutesprocainamide - 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

unstablecardioversion – 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/defibrillation

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/defibrillation

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

epinephrine0.01mg/kg (1:10 000) q3-5 min during

arrest0.1mg/kg (1:1000) intratracheal

0.1-0.2mg/kg (1:1000) “high dose” not recommended

pharmacology - atropine

atropine0.02 mg/kgminimum 0.1 mg – < paradoxical bradymax 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 chloride0.2 mL/kg of 10% calcium chlorideslow infusion 20secs in arrest; 10 mins in

perfusing rhythm

indicationshypocalcemiahypermagnesemia?PEA ?asystole – not recommended

pharmacology - magnesium

25-50 mg/kg

indications 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, placebo-controlled trial. J Pediatr. 1996;129:809–814

pharmacology - glucose

infantshigh glucose requirements low glycogen storesprone to hypoglycemia during stress

monitor glucose frequently0.5 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, perfusionNB. again, most arrest respiratory – therefore NaHCO3 could exacerbateindications 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 H2Oadjust to blood gases - PCO2 35

circulation

ongoing fluid resuscitationinotropes/vasopressors/vasodilatorsinitially, may be unclear – intensive monitoring environmentshock 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?