Paediatric resuscitation
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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

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Paediatric Resuscitation

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Paediatric resuscitation

Paediatric Resuscitation

November 2001


Contents

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

age definitions

  • newly born – first hours of life

  • neonate – first month

  • infant – neonate to 1 year

  • child – 1yr – 8yrs

  • adolescent - >8 yrs


Epidemiology

epidemiology

  • CPR is provided for only approximately30% 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

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


Eitiology1

eitiology

  • much less likely primarily cardiac

  • in general…

    • progression from hypoxia and hypercarbia (respiratory failure) OR shock  respiratoryarrest and bradycardia  asystolic cardiac arrest

  • therefore – ventilation (CPR) priority over defib (vs. adults)

  • recognize early respiratory failure and shock prevent arrest


Eitiology2

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

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


Paediatric resuscitation

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;89:642-3

    • case series published in neonates – no patient outcomes


Intubation

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

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


Paediatric resuscitation

RSI


Preoxygenation

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

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


Premedication1

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

sedation

  • thiopental – can induce bronchospasm (relatively contraindicated in asthmatics)

  • infants/neonates – more sensitive to fentanyl

  • fentanyl may increase ICP in children


Paediatric resuscitation

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

TABLE 3 -- Suggested sedatives for selected clinical situations.


Paralysis sux

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

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

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


Intubation1

intubation

  • Miller blade or Mac in older

  • tube size 4 + age/4

  • attemptsshould not exceed 30 seconds

    • bradycardia (<60)

    • hypoxia

  • depth of insertion (cm)

    • tube ID (in mm) x 3.

    • in children >2 years of age

      • depthof insertion (cm) = (age in years/2)+12.

    • direct visualization or breslow

  • confirm placement – end tidal CO2 etc


Relative contraindications

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 pre hospital setting

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 improvesurvival over bag-mask ventilation in all EMS systems

  • endotrachealintubation appears to result in increased airway complications


Breathing

breathing

  • signs of respiratory failure/impending arrest

    • increased respiratory rate

    • distress/increased respiratoryeffort

    • inadequate respiratory rate, effort, or chest excursion

    • diminished breath sounds

    • gasping or grunting respirations

    • decreasedlevel of consciousness or response to pain

    • poor skeletal muscletone

    • cyanosis


Circulation

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 acidosison laboratory evaluation


Circulation1

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)

    • heyond10 years, SBP <90 mmHg

  • NB. remember – hypotension is late finding in shock suggesting impending arrest


Paediatric resuscitation

CPR

  • chest compressions with backboard

    • two handed in infants

  • internal cardiac massage not recommended

    • chest wall compliance


Vascular access

vascular access

  • peripheral

  • interosseous

    • anteriortibial 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

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

fluids

  • NS, LR

  • blood

    • refractory shock to 40-60cc/kg crystalloid

  • no evidence for colloid or HTS


Neonatal resuscitation

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 resuscitation1

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 resuscitation2

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 meds

  • 4. evaluate color  blue?  supplemental O2


Meconium

meconium

  • 10-20% of all deliveries

  • intervention only with thick, particulate stained amniotic fluid

  • suction 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

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

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


Bradyarrhythmias1

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

transcutaneous pacing

  • < 15kg  paediatric electrodes

  • > 15kg  adult

  • positioning

    • anterior (+) – posterior (-)

    • R infraclavicular (+) – L midaxillary 4th ICS (+)


Paediatric resuscitation

PEA

  • often represents apreterminal condition that immediately precedes asystole

  • frequently represents the final organized electrical state ofa severely hypoxic, acidotic myocardium


Paediatric resuscitation

PEA

  • hypovolemia

  • hypoxemia

  • hypothermia

  • hyperkalemia

  • tension pneumothorax

  • pericardial tamponade

  • toxins

  • pulmonarythromboembolus


Paediatric resuscitation

PEA

  • oxygenate

  • ventilate

  • CPR

  • fluid resuscitate

  • epinephrine

  • special interventions


Tachycardia

tachycardia

  • narrow complex

    • SVT – most common arrythmia

    • sinus tachycardia

  • wide complex

    • abberancy – uncommon

    • VT/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 vs sinus tachycardia


Svt options

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

ventricular arrhythmias – VT/VF

  • uncommon in children

  • eitiology

    • congenital heart dz, cardiomyopathy, myocarditis

    • reversable causes

      • metabolic (hyperK,hyperMg, hypoCa, hypoglyc)

      • drug toxicity

      • hypothermia


Paediatric resuscitation

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

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

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 defibrillation1

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

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

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

pharmacology – vasopressin

  • Vasopressin

    • systemic vasoconstriction

      • selective vasoconstriction of skin, skeletal muscle, intestine, and fat

      • relatively lessvasoconstriction of coronary, cerebral, and renal vascularbeds

    • reabsorptionof water in the renal tubule

  • Not studied in paediatric arrest – not recommended


Pharmacology calcium

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

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

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

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

pharmacology - naloxone

  • neonatal resuscitation

  • in mother whom received narcotics during delivery

  • dose : 0.1 mg/kg IM/IV/SC/ET


Post resuscitation care

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 ofillness

  • tertiary-caresetting


Airway breathing

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


Circulation2

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

termination of resuscitation

  • in general, 30 minutes

  • absence of hypothermia, toxic drug overdose

  • NB. ?family present during resuscitation?


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