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Pediatric Cardiac Arrest: Old Evidence and New Guidelines. Tim Lynch, MD April, 2001. Resuscitation. Reanimation (Fr) Resuscitare (L) – the restoration of life of one apparently dead. Case Study.

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Pediatric Cardiac Arrest: Old Evidence and New Guidelines

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Pediatric cardiac arrest old evidence and new guidelines l.jpg

Pediatric Cardiac Arrest: Old Evidence and New Guidelines

Tim Lynch, MD

April, 2001


Resuscitation l.jpg

Resuscitation

  • Reanimation (Fr)

  • Resuscitare (L) – the restoration of life of one apparently dead


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Case Study

  • A 5-year old girl is brought to your emergency department by paramedics after being found at home to be apneic, and pulseless. She has received only BVM ventilation and chest compressions en route.


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Case Study: Questions/Objectives

  • Why do children arrest?

  • What are the likely outcomes of these children?

  • What’s your dose of epinephrine and why?

  • What are these new agents and when do we use them?


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Why do children arrest?


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Pediatric cardiopulmonary resuscitation. A review of 130 cases.Ludwig S et al Clin Pediatr 1984;23:71-75

  • Review of patients suffering cardiorespiratory arrest at Children’s Hospital of Philadelphia between 1976 and 1980 (ED, Medical, and Surgical Units)


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Pediatric cardiopulmonary resuscitation. A review of 130 cases.Ludwig S et al Clin Pediatr 1984;23:71-75

  • 130 arrests - 96 hospital and 34 ED’s

  • mean age of 2 and 65 % less than 12 months


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Pediatric cardiopulmonary resuscitation. A review of 130 cases.Ludwig S et al Clin Pediatr 1984;23:71-75

  • ED (34 with 42 diagnoses)

    • Respiratory (14)

    • CNS (9)

    • CVS (8)

    • SIDS (6)

    • DOA (4)

      • rigor mortis, low temperature, asystole


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Pediatric cardiopulmonary resuscitation. A review of 130 cases.Ludwig S et al Clin Pediatr 1984;23:71-75

  • Respiratory (14)

    • 4 pneumonia

    • 3 aspiration

    • 2 asthma

    • 2 respiratory failure

    • 1 epiglottitis

    • 1 restrictive

    • 1 RDS


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Pediatric cardiopulmonary resuscitation. A review of 130 cases.Ludwig S et al Clin Pediatr 1984;23:71-75

  • CNS (9)

    • 6 trauma

    • 2 seizure

    • 1 hydrocephalus


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Pediatric cardiopulmonary resuscitation. A review of 130 cases.Ludwig S et al Clin Pediatr 1984;23:71-75

  • Cardiovascular (8)

    • 4 CHD

    • 2 sickle cell

    • 1 CHF

    • 1 hemophilia


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Pediatric cardiopulmonary resuscitation. A review of 130 cases.Ludwig S et al Clin Pediatr 1984;23:71-75

  • Hospitalized Patients (96 with 133 diagnoses)

    • Respiratory (57)

    • Cardiovascular (28)

    • CNS (25)

    • GI (7)

    • Miscellaneous (16)


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Pediatric cardiopulmonary resuscitation. A review of 130 cases.Ludwig S et al Clin Pediatr 1984;23:71-75

  • Respiratory (57)

    • 26 RDS/BPD - 1 epiglottitis

    • 12 pneumonia- 1 choanal atresia

    • 4 apnea- 1 pulm hemosidero

    • 3 bronchiolitis- 1 botulism

    • 3 aspiration

    • 3 trach obstruction

    • 2 respiratory failure


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Pediatric cardiopulmonary resuscitation. A review of 130 cases.Ludwig S et al Clin Pediatr 1984;23:71-75

  • CNS (25)

    • 10 hydrocephalus

    • 5 tumour

    • 4 meningitis

    • 2 seizure

    • 2 anoxic encephalopathy

    • 1 hemorrhage

    • 1 microcephaly


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Pediatric cardiopulmonary resuscitation. A review of 130 cases.Ludwig S et al Clin Pediatr 1984;23:71-75

  • GI (7)

    • 3 NEC

    • 1 appendicitis

    • 1 Hirschsprung’s

    • 1 TE Fistula

    • 1 SBO


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Pediatric cardiopulmonary resuscitation. A review of 130 cases.Ludwig S et al Clin Pediatr 1984;23:71-75

  • Miscellaneous (16)

    • 6 congenital (non-cardiac)

    • 5 tumours (non-CNS)

    • 2 genetic

    • 1 drug ingestion

    • 1 ITP

    • 1 metabolic


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What are the likely outcomes of these children?


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Outcome of children who are apneic and pulseless in the emergency roomO’Rourke P, Crit Care Med 1986;14:466-468

  • To examine mortality and morbidity of patients successfully resuscitated after arriving pulseless and apneic

  • 3-year retrospective chart review of patients admitted from the ED to ICU over 3 years in Children’s Hospital, Boston


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Outcome of children who are apneic and pulseless in the emergency roomO’Rourke P, Crit Care Med 1986;14:466-468

  • 34 patients admitted to ICU post-resuscitation

  • 27 died in the ICU

  • 7 were discharged from the hospital


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Patient Profiles


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Etiology


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The Resuscitation


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Outcome of children who are apneic and pulseless in the emergency roomO’Rourke P, Crit Care Med 1986;14:466-468

  • 27 died in the ICU

    • 7 due to cardiovascular instability

    • 20 removed from life support diagnosed with brain death

  • 7 discharged from the ICU to chronic care

    • 4 were victims of near drowning

      • 2 vegetative; 1died secondary to obstructed trach

      • 1 functioning at 9 mo level at age 4

  • 2 with upper airway obstruction - both vegetative

  • 1 with blunt chest trauma - vegetative


  • Results of inpatient pediatric resuscitation gillis j et al crit car med 1986 14 469 471 l.jpg

    Results of inpatient pediatric resuscitationGillis, J et al. Crit Car Med 1986:14;469-471

    • Retrospective review of arrests at HSC over 1 year

    • outcomes at 6 months

    • predictive accuracy of variables considered to influence survival


    Results of inpatient pediatric resuscitation gillis j et al crit car med 1986 14 469 47125 l.jpg

    Results of inpatient pediatric resuscitationGillis, J et al. Crit Car Med 1986:14;469-471

    • Respiratory Arrest - cessation of breathing for longer than 1 minute without apparent loss of cardiac output

    • Cardiac Arrest - apneic with no cardiac output (no recordable BP or femoral pulse)


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    Results of inpatient pediatric resuscitationGillis, J et al. Crit Car Med 1986:14;469-471

    • 42 attempted resuscitations (9 - respiratory; 33 - cardiac)

    • 21 females and males; mean age 5.5 y

    • overall survival of 17 % (9% cardiac arrests)

    • 7 alive at 6 months - 1 with severe neurologic deficit


    Results of inpatient pediatric resuscitation gillis j et al crit car med 1986 14 469 47127 l.jpg

    Results of inpatient pediatric resuscitationGillis, J et al. Crit Car Med 1986:14;469-471


    Results of inpatient pediatric resuscitation gillis j et al crit car med 1986 14 469 47128 l.jpg

    Results of inpatient pediatric resuscitationGillis, J et al. Crit Car Med 1986:14;469-471


    Results of inpatient pediatric resuscitation gillis j et al crit car med 1986 14 469 47129 l.jpg

    Results of inpatient pediatric resuscitationGillis, J et al. Crit Car Med 1986:14;469-471

    • All 33 % with pre-existing cardiac disease had a cardiac arrest

    • 30/33 with asystole

    • 3/33 with intractable ventricular fibrillation


    Results of inpatient pediatric resuscitation gillis j et al crit car med 1986 14 469 47130 l.jpg

    Results of inpatient pediatric resuscitationGillis, J et al. Crit Car Med 1986:14;469-471


    Results of inpatient pediatric resuscitation gillis j et al crit car med 1986 14 469 47131 l.jpg

    Results of inpatient pediatric resuscitationGillis, J et al. Crit Car Med 1986:14;469-471


    Results of inpatient pediatric resuscitation gillis j et al crit car med 1986 14 469 47132 l.jpg

    Results of inpatient pediatric resuscitationGillis, J et al. Crit Car Med 1986:14;469-471

    • Respiratory (4):

      • 2 with hydrocephalus and blocked shunts

      • 1 with lymphoma and 1 with cystic hygroma

  • Cardiac (3):

    • CCHD and arrythmia

    • esophageal atresia and recurrent aspiration

    • 3 yo girl with CCHD and pneumonia - arrested for 12 min and received epi once

      • spastic quadriplegia


  • Results of inpatient pediatric resuscitation gillis j et al crit car med 1986 14 469 47133 l.jpg

    Results of inpatient pediatric resuscitationGillis, J et al. Crit Car Med 1986:14;469-471

    • Respiratory arrests had better outcome

    • predictors of non-survival:

      • > 15 minutes of CPR

      • administration of more than 1 dose of epi


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    What’s your dose of epinephrine and why?


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    High-dose epinephrine improves outcome from pediatric cardiac arrestGoetting MG et al, Ann Emerg Med 1991;20:22-26

    • Compared a prospectively treated high-dose epinephrine (HDE) study group with historical cohorts receiving conventional dose (SDE) with respect to the return of spontaneous circulation (ROSC)


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    High-dose epinephrine improves outcome from pediatric cardiac arrestGoetting MG et al, Ann Emerg Med 1991;20:22-26

    • 20 consecutive patients treated for cardiac arres who failed ROSC after 2 doses of SDE (0.01 mg/kg) five min apart were given HDE (o.2 mg/kg) in 1:10 000 for infants and 1:1000 for older patients


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    High-dose epinephrine improves outcome from pediatric cardiac arrestGoetting MG et al, Ann Emerg Med 1991;20:22-26

    • Iv line was flushed after each dose

    • atropine 0.01 mg/kg was given for bradycardia and asystole with each SDE

    • sodium bicarbonate 1 mEq/kg was administered between each SDE

    • all patients ventilated with 100 % O2


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    High-dose epinephrine improves outcome from pediatric cardiac arrestGoetting MG et al, Ann Emerg Med 1991;20:22-26

    • ROSC was defined as

      • a supraventricular rhythm with palpable pulses or

      • an invasive systolic pressure greater than 60 mm Hg


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    High-dose epinephrine improves outcome from pediatric cardiac arrestGoetting MG et al, Ann Emerg Med 1991;20:22-26

    • historic controls -

      • 20 consecutive children treated by the same author over 12 months

      • with witnessed arrests,

      • receiving ACLS within 5 min, and

      • receiving more than 2 SDE’s


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    High-dose epinephrine improves outcome from pediatric cardiac arrestGoetting MG et al, Ann Emerg Med 1991;20:22-26

    • 14 of HDE had ROSC within 5 minutes versus none of the controls (p<0.001)

      • all 14 responded with sinus tachycardia for at least 15 min

      • mild to moderate hypertension for 20 min in 8

      • 10 placed on vasopressor drips


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    High-dose epinephrine improves outcome from pediatric cardiac arrestGoetting MG et al, Ann Emerg Med 1991;20:22-26

    • 14 survivors:

      • 8 survived to discharge:

        • 6 regained pre-arrest neurologic level

          • 3 developmentally normal 6 - 17 mo later (pulmonary contusions, hypovolemia, septic shock)

          • 3 regained severe pre-existing cognitive level

        • 2 with global cortical damage


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    What are these new agents and when do we use them?


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    New Guidelines

    • amiodarone

    • procainamide

    • lidocaine


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    Amiodarone

    • Inhibits outward K current - prolongs QT

    • Inhibits Na channels - slows and conduction (prolongs QRS)

    • Non-competitive inhibitor of alpha- and beta-adrenergic receptors

      • secondary to sympathetic block - vasodilatation and AV nodal suppression Non-competitive


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    Amiodarone

    • Most commonly used for ectopic atrial tachycardia or junctional ectopic tachycardia post cardiac surgery

    • 5 mg/kg loading infusion over minutes to 15 mg/kg/day

    • hypotension is the main adverse effect


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    Procainamide

    • Sodium channel blocking agent - prolongs refractory period and depresses conduction velocity - prolonged QT and PR intervals

    • effective for atrial fibrillation and flutter, SVT, JET, and perfusing VT


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    Procainamide

    • Must be given by slow infusion to avoid heart block, myocardial depression, and prolonged QT

    • 15 mg/kg over 30 to 60 min

      • stop infusion if hypotension or QRS widens to > 50 % of baseline


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    Lidocaine

    • Not effective for ventricular arrhythmias in infants or children unless associated with focal myocardial ischemia

    • may be considered in shock-resistant VF or pulseless VT

    • 1 mg/kg bolus then 20 to 50 ug/kg/min


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    IV, IO

    ET

    Asystole/

    Pulseless Arrest

    Standard

    High

    First Dose

    0.01 mg/kg 1:10000

    0.1 mg/kg 1:1000

    0.1 ml/kg 1:10000

    0.1 ml/kg 1:1000

    Repeat Doses

    High

    High

    Pediatric Epinephrine Dosing


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    Epinephrine

    • Alpha and beta-adrenergic properties

      • Alpha-adrenergic vasoconstriction

      • Increases aortic diastolic pressure and coronary perfusion


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    High Dose Epinephrine

    • 10 to 20 times the standard dose

    • A dangerous dose in one patient may be lifesaving in another

      • Improved survival and neurological outcome

      • Increased myocardial consumption and post arrest hyperadrenergic state


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    New Guidelines: Epinephrine

    • The conventional dose of epinephrine is recommended for second and subsequent doses

    • Higher doses may be considered


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    New Guidelines: Bradycardia

    • Atropine is recommended in the treatment of symptomatic bradycardia caused by AV block or increased vagal tone


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    New Guidelines: SVT

    • Vagal maneuvers introduced

    • Verapamil remains contraindicated in infants

    • Amiodarone

    • Procainamide


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    New Guidelines: Stable VT

    • Amiodarone

    • Procainamide or lidocaine considered alternative agents


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    New Guidelines: Pulseless VT/VF

    • Defibrillation 2 J/kg, 4 J/kg, 4 J/kg

    • Epinephrine

    • Amiodarone


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    Dose

    Remark

    Pulseless VF/VT

    5 mg/kg IV/IO

    Bolus

    Hypotension

    Perfusing Tachycardias

    5 mg/kg IV/IO

    (15mg/kg/day)

    Infuse over 20-60 min

    Amiodarone


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    Dose

    Remarks

    Perfusing Tachycardias

    15 mg/kg IV/IO

    Infuse over 30 – 60 min

    Procainamide


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