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Rationale for the Current Paediatric Resuscitation Guidelines Bob Bingham RC (UK) PowerPoint PPT Presentation

Rationale for the Current Paediatric Resuscitation Guidelines Bob Bingham RC (UK) Evidence? Janssens L, Altman S, Rogers PA. Vet Rec;105(12):273-6. Respiratory and cardiac arrest under general anaesthesia: treatment by acupuncture of the nasal philtrum.

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Rationale for the Current Paediatric Resuscitation Guidelines Bob Bingham RC (UK)

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Rationale for the Current Paediatric Resuscitation Guidelines

Bob Bingham RC (UK)

Paediatric Anaesthesia Study Day


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Evidence?Janssens L, Altman S, Rogers PA.Vet Rec;105(12):273-6.

Respiratory and cardiac arrest under general anaesthesia: treatment by acupuncture of the nasal philtrum.

“In seven cases of anaesthetic apnoea with concurrent cardiac arrest and absence of vital signs, the revival rate was 43 per cent. Those which recovered required four to 10 minutes of acupuncture stimulation”

Paediatric Anaesthesia Study Day


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Plan

  • Evidence evaluation

  • BLS issues

    • AEDs

  • ALS issues

  • Aspects of airway management

  • Conclusions

Paediatric Anaesthesia Study Day


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What we know for sure

  • Children usually suffer from secondary cardiac arrest

  • In c.90% of cases bradycardia precedes asystole/PEA

  • Survival from respiratory arrest is good (c.70% normal at 1 year)

  • Bystander CPR is associated with improved survival

  • Rescuers often do nothing for fear of causing harm - because they’re scared that “children are different”

Paediatric Anaesthesia Study Day


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The Big Idea

A universal guideline for all

Paediatric Anaesthesia Study Day


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“For every complex problem there is an answer that is simple, neat and wrong.”

H L Menken

Paediatric Anaesthesia Study Day


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Effectiveness of ventilation–compression ratios 1:5 and 2:15 in simulated single rescuer paediatric resuscitation E. Dorph, L. Wik and P. A. Steen. Resuscitation 2002;54:259

Paediatric Anaesthesia Study Day


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Optimum Compression:Ventilation ratio

  • More compressions, better CPP

  • More ventilation better oxygenation

  • Optimum Balance?

Paediatric Anaesthesia Study Day


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Optimum Compression:Ventilation ratioBabbs CF, Kern KB. Resuscitation 2002;54:147-57

Paediatric Anaesthesia Study Day


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Optimal CPR in ChildrenBabbs CF, Nadkarni V. Resuscitation 2004;61:173

“Compression to ventilation ratios in CPR should be smaller for children than for adults and gradually increase as a function of body weight. Optimal CPR in children requires relatively more ventilation than optimal CPR in adults”.

Paediatric Anaesthesia Study Day


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So much for the

“Big Idea”

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CC+V

CC

V

No CPR

ROSC

10 /10

6 /10

6 /10

4 /10

ROSC (<2 min)

10 /10

4 /10

6 /10

0 /10

1-h survival

10 /10

6 /10

6 /10

4 /10

24-h survival

8 /10

5 /10

6 /10

0 /10

24-h neurologically normal

8 /10

4 /10

6 /10

0 /10

Piglet Model of Asphyxial Cardiac ArrestBerg et al 1999. Crit Care Med;27:1893-99

Paediatric Anaesthesia Study Day


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Doing anything is better than doing nothing

  • Ideally children should have a lower compression/ventilation ratio than adults

  • It’s no use having an ideal if no-one does anything

Paediatric Anaesthesia Study Day


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Solution

  • Those “with a duty to respond” will do something. They should employ the optimum, evidence based, sequence

  • Other responders should be encouraged to do something by making only minimal necessary modifications to the adult protocol

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BLS simplifications

  • Much of the wording harmonised with the adult text

  • Age limits: If you think the victim is a child, then he/she is!

  • Chest compression landmarks – avoiding abdominal compression

  • AEDs

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AEDs

Problem is not giving too large a shock to a child in VF

Problem is giving ANY shock to child not in VF

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Fear of Doing Harm

  • LD50 of shock = 470J/kgBabbs et al. Am Heart J 1980;99:734-738

  • LD100 = 0Jkg(if in VF)

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AEDs In Children:Rhythm Analysis

Hazinski et al; Circulation 1997Sensitivity 100%; Specificity 100%

Atkins et al; Pediatrics 1998Sensitivity 88%; Specificity 100%

Ceccin et al; Circulation 2002Sensitivity 100% for VF; Specificity 100%

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Heartstart® FR2 Automated External Defibrillator (50J attenuator)

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Attenuated AEDsAtkins DL, Jorgenson DB. Resuscitation 2005;66:31-37

Pads applied to 27 Patients

  • 8 were in VF (age: 4.5 months - 10 years)

  • Shocks were advised and delivered to all

  • No shock advised to any of the others

  • All 8 defibrillated and admitted to hospital

  • 5 discharged

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50 meters this way, you say?

Are we going in the right direction?

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ALS

  • ALS protocol

  • VF

  • Dose of adrenaline

  • Airway management

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RhythmSamson R, Nadkarni V et al. NEJM 2006;354:2328

Prospective study of 1005 children with

in-hospital cardiac arrest:

  • Non-shockable rhythm 73%

    • Survival 27%

  • Shockable rhythm 27%

    • Survival:

      • 35% (if VF initial rhythm)

      • 11% (if VF occurred subsequently)

Paediatric Anaesthesia Study Day


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Paediatric Anaesthesia Study Day


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VF Protocol

  • Different aetiology - therefore consider precipitating causes

  • Otherwise, no reason to differ from adult sequence

  • 4J/kg only

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Dose of Adrenaline?

10mcg/kg?

100mcg/kg?

For the 1st dose

For the 2nd dose

For subsequent doses

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High dose adrenaline

  • Supported by animal studies and a single retrospective study in children:

  • No other studies have shown benefit

0/20 survivors after at least two SDE (historical control group)

14/20 survivors with HDE after two failed SDE

8/20 survived to discharge

3/20 neurologically intact at follow-up

Goetting. Annals Emerg Med 1991

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High dose adrenaline

  • Perondi et al NEJM 2004;250:1722-30

    • Blinded PRCT

    • 68 subjects randomised to HDE or SDE after 1x failed SDE

    • 24 hr survival HDE: 1/34SDE: 7/34

    • Difference significant, but not maintained following adjustment for differences between the 2 groups

    • Significantly reduced survival from asphyxial arrest in HDE group

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Airway Management

  • The “Gold Standard”

  • LMA

  • Cuffed tracheal tubes

  • Other devices

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Effect of out-of-hospital paediatric endotracheal intubation on survival and neurological outcome: a controlled clinical trial.JAMA. 2000 Feb 9;283(6):783-90. Gausche M, Lewis RJ, Stratton SJ, Haynes BE, Gunter CS, Goodrich SM, Poore PD, McCollough MD, Henderson DP, Pratt FD, Seidel JS.

  • Prospective randomised controlled trial

  • 830 consecutive patients (<12 years old)

  • Randomised to BVM or ETI on odd or even dates

  • Outcomes: survival to hospital discharge and neurological status on discharge

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Outcome by Treatment Received

ETI group 420BVM group: 410

Survival

  • ETI:25/185 (14%)

  • BVM:208/635 (33%)

    Good neurological outcome

  • ETI:15/185 (8%)

  • BVM:162/635 (26%)

    BUT: results were (correctly) analysed on an ‘intention to treat’ basis

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Gausche et alJAMA. 283(6):783-90, 2000

Outcomes

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Gausche et alJAMA. 283(6):783-90, 2000

Complications

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LMAs?Lopez-Gil M, Brimacombe J et al. (1996)

  • 8 anaesthesia residents

  • 75 patients each (600 in all)

  • The problem rate per patient for overall, major, and minor problems was 31.5%, 12.8%, and 18.7%, respectively

  • The problem rate decreased from 62% to 2% for overall problems and 23% to 2% for major problems over the 75 patients

Paediatric Anaesthesia Study Day


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Cuffed Tracheal TubesKhine et al Anesthesiology 1997;86:627-31

488 children (0-8yrs) undergoing general anaesthesia

  • Initial size tube selected correctly more frequently with cuffed (age/4+3)

  • Less leak

  • Same complication rate

Paediatric Anaesthesia Study Day


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Laryngeal Tube

  • 0Newborn<5kg

  • Infant5-12Kg

  • Child12-25kg

  • Small adult<155cm

  • Medium adult155-180cm

  • 5Large adult>180cm

Paediatric Anaesthesia Study Day


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Laryngeal TubevsLMABortone L et al 2006. Paed Anaesth;16:251-7

Paediatric Anaesthesia Study Day


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ETCO2 Monitoring

Tracheal tube placement detection reliable with perfusing rhythm and during transport

What about during cardiac arrest?

(Bhende et al Am J Emerg Med 1996;14:349-50)

  • Sensitivity 85%

  • Specificity 100%

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Questions?

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Conclusions

Paediatric resuscitation guidelines 2005

  • Are evidence based - but it’s not level 1 evidence!

    They are:

  • Simpler for professional rescuers

  • Much simpler for lay rescuers

Paediatric Anaesthesia Study Day


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