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pediatric resuscitation: 2005 hsfc aha pals guidelines

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pediatric resuscitation: 2005 hsfc aha pals guidelines

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    1. 2007 Stollery PICU Conference Pediatric Resuscitation: 2005 HSFC & AHA PALS Guidelines Allan de Caen MD, FRCP(C) PICU, Stollery Childrens Hospital University of Alberta Edmonton, Canada

    2. 2007 Stollery PICU Conference Objectives Major PALS Guidelines changes for 2006 Pediatric cardiopulmonary arrest prognostication CPR technique and the role of ventilation vasopressor/ catecholamine use ETT and IO drug delivery defibrillation post-resuscitation temperature management cuffed vs. uncuffed ETT

    3. 2007 Stollery PICU Conference

    4. 2007 Stollery PICU Conference EMS patches in to the ED giving a heads-up that they are 5 minutes out with a 3 week old child with presumed sepsis that is in cardiac arrest in their ambulance. What resuscitation algorhythm do you follow: neonate or child?

    5. 2007 Stollery PICU Conference NRP Newlyborn: newborn until d/c from nursery Infant: d/c from nursery to 1 yo Child Layperson: 1 yo to 8 yo (AED-related defn) Health care provider: 1 yo to S/S of puberty ACLS for the teenager in crisis?

    6. 2007 Stollery PICU Conference ALS care has been provided for 15 minutes. How long should you continue resuscitation for?

    7. 2007 Stollery PICU Conference Outcome from Cardiopulmonary Arrest (CPA) in Children is poor. Out of hospital CPA Survival to hospital D/C: 2-15% Sirbaugh 1999, Young 2004, Herlitz 2005, Lopez-Herce 2005 ? 6 month/ 1 year survival; CNS status? In-hospital CPA 24 hr survival: 33-37% 1 yr survival: 10-20% 72-83% still at pre-CPA Neuro baseline Torres 1997, Suominem 2000, Reis 2002

    8. 2007 Stollery PICU Conference Why is outcome of pediatric cardiac arrest so poor? Minority of pre-hospital pediatric cardiac arrests have CPR provided by bystanders on scene (significant delay in time to CPR) 39% (Mogayzel, 1995) 26% (Sirbaugh, 1999) 31% (Young, 2004) 68 % (Herlitz, 2005)

    9. 2007 Stollery PICU Conference Pediatric CPA: Prognostication Previously used markers for limiting duration of resuscitation (ie. ~20 minutes or 2 rounds of epinephrine) may now be inaccurate, especially when CPAs occur in ECLS centres

    10. 2007 Stollery PICU Conference What compression: ventilation ratio should be used for this 3 week old infant, and why? 3:1 5:1 15:2 30:2

    11. 2007 Stollery PICU Conference What does CPR do? The critical effect of chest compressions is the generation of coronary artery perfusion pressure (CAPP) the higher the coronary perfusion pressures, the better the survival Halperin 1986, Feneley 1988, Paradis 1990

    12. 2007 Stollery PICU Conference Ventilation impedes effective chest compressions 30% of is time in a single rescuer 5:1 C/V ratio is lost in transferring between compressions and ventilations Whyte and Wyllie, Resuscitation, 1999 15:2 ratios limit the maximum number of compressions provided by single rescuers to 45 per minute, due to the 16 second pause in compressions needed to deliver 2 breaths (effectively?) Chamberlain et al, Resuscitation, 2002

    13. 2007 Stollery PICU Conference Ventilation impedes effective chest compressions

    14. 2007 Stollery PICU Conference ABGs after 7 min of CPR for VF-CPA

    15. 2007 Stollery PICU Conference VF-CPA and CNS Outcome (12 min of CPR after 3 min of VF)

    16. 2007 Stollery PICU Conference Asphyxial-CPA and C:V ratios (after 7 min of CPR following asphyxial CPA)

    17. 2007 Stollery PICU Conference Asphyxial-CPA and C:V ratios

    18. 2007 Stollery PICU Conference Science Summary More CC / min are associated with greater coronary perfusion pressures and greater survival in animal models Ventilation is relatively unimportant in the first 10 minutes after collapse from VF Early ventilation is necessary when resuscitating asphyxial cardiac arrest, but a 15:2 ratio may be adequate Withholding chest compressions for 20 sec can reduce the probability of resuscitation from 50% to 8% Eftestol, Circulation, 2002

    19. 2007 Stollery PICU Conference Pediatric BLS 2005 For unwitnessed cardiac arrest Child: phone fast 2 minutes CPR, then leave to call 911/ retrieve AED Adult: Lay rescuer: call first (> 8yo) HCP: call fast if suspected asphyxial arrest (eg. drowning/ injury) (post-pubertal) For sudden witnessed collapse Child and adult: phone first apply AED/ defibrillator as soon as available Wik, JAMA, 2003

    20. 2007 Stollery PICU Conference CPR: Guidelines 2005 Infants (older than the newlyborn) and children (to puberty) will be resuscitated with C:V ratios of: 30:2 single rescuer (generally pre-hospital lay rescuer) 15:2 two rescuer (health care provider) Children with signs of puberty will be resuscitated with C:V ratio of 30:2, both by lay rescuer and health care provider, in-hospital and out of hospital The universal pre-hospital algorhythm will hopefully lead to more patients actually getting pre-hospital CPR (easier to teach, learn and perform)

    21. 2007 Stollery PICU Conference Take-away messages CPR Harder Faster Dont lean on the chest Minimize interruptions (pulse/ rhythm checks/ time for intubation or ventilation)

    22. 2007 Stollery PICU Conference EMS has been unable to intubate the infant. Is there a down-side to even taking the time to successfully intubate this infant? What kind of ETT should be used; cuffed vs uncuffed, or does it matter?

    23. 2007 Stollery PICU Conference How effectively are we BVM ventilating anyways? (pediatric mannequin study)

    24. 2007 Stollery PICU Conference Time to place a secured airway during CPA

    25. 2007 Stollery PICU Conference Cuffed vs. Uncuffed ETT in Children AGAINST Cuffed tubes Cuff unnecessary, (normal subglottic narrowing) Subglottic mucosal injury potentially resulting in tracheal stenosis (pressure injury if unmonitored). The correct placement of the tube is more difficult when using a cuffed tube Use of a cuffed tube requires a slightly smaller tube for age (0.5-1.0mm), which increases airway resistance and hence increases spontaneous breathing effort. FOR the use of cuffed tubes A glottic airleak may complicate ventilator management (ie. if poor lung compliance/ high airway resistance (**). Reduced risk of aspiration. More accurate measurement of end-tidal CO2

    26. 2007 Stollery PICU Conference Cuffed vs. Uncuffed ETT in Children Newth, J Peds, 2004 1 yr prospective study investigating incidence of airway complications after extubation of children (< 5yo) with cuffed or uncuffed ETTs (PICU) No significant difference in airway complications

    27. 2007 Stollery PICU Conference Guidelines 2005 and the use of cuffed ETTs in pediatrics In the in-hospital setting, a cuffed tracheal tube is as safe as an uncuffed tube for infants (except the newlyborn) and children (no difference in airway complications) Newth, J Peds, 2004 In certain circumstances (eg, poor lung compliance, high airway resistance, or a large glottic air leak) a cuffed tube may be preferable, provided that attention is paid to tracheal tube size, position, and cuff inflation pressure

    28. 2007 Stollery PICU Conference PALS Airway Guidelines 2005 LMAs are acceptable when used by experienced providers While EtC02 monitoring is more commonly used, esophageal detector devices can be used to confirm endotracheal tube position in children >20 Kg who have a perfusing rhythm Cuffed ETT size calculation Cuffed ETT size = (Age (years/ 4) + 3

    29. 2007 Stollery PICU Conference The RT asks you how quickly you would like to ventilate this patient? You pause and consider the issues Does excessive assisted ventilation worsen outcome of CPA victims? What is excessive ventilation?

    30. 2007 Stollery PICU Conference CPR/ ventilation and the secured airway Adults in pre-hospital CPA were ventilated by paramedics at a rate of 37+/- 4 bpm Aufderheide et al, Circulation, 2004 Adults (in-patient) having a CPA are frequently hyperventilated during resuscitation < 10 bpm 7.3% > 20 bpm 60.9% Abella BS, JAMA, 2005 Children being hand-ventilated appear to be to over-ventilated more than half (~62%) of the time Tobias et al, Ped Emerg Care, 1996

    31. 2007 Stollery PICU Conference

    32. 2007 Stollery PICU Conference Does hyperventilation worsen outcome in the non-arrested shocky patient?

    33. 2007 Stollery PICU Conference How much should we ventilate critically ill children in 2005? Using normal respiratory rates is probably over-ventilating when pulmonary blood flow is only a fraction of normal (arrested or shocky patient) Guidelines 2005 If patient in cardiac arrest Ventilate using 15:2 C:V ratio once advanced airway in place, RR 8-10 bpm regardless of age), unsynchronized with CC if patient has a pulse RR 12-20 bpm Take a deep breath, take your own pulse, and then ventilate slowly (it will still probably be too fast!!)

    34. 2007 Stollery PICU Conference While assessing the infant, you note that he is pulseless. After initiating CPR, you consider the issue of what drug to give. Vasopressin? Epinephrine? Atropine? By what route and how much should you deliver?

    35. 2007 Stollery PICU Conference Epinephrine and Pediatric CPA While animal studies have shown that epinephrine increases coronary and cerebral blood flow during resuscitation, no human clinical evidence has demonstrated that epinephrine actually alters the long-term outcome (hospital admission, hospital d/c, neurological outcome) of pediatric or adult CPA Young, 2004 49% of pediatric CPA survivors responded to CPR alone, and did not require epinephrine

    36. 2007 Stollery PICU Conference High Dose Epinephrine: Are we doing harm? Worsened post-resuscitation myocardial function Increased afterload Increased myocardial metabolic work Post-resuscitation myocardial failure/ death Pro-dysrhythmic state Worsened cerebral acidosis associated with high-dose epinephrine (uncoupling of oxidative phosphorylation): worsening neurological outcome?

    37. 2007 Stollery PICU Conference Pediatric epinephrine dosing: understanding the literature Limited number of human studies into HDE (n = 4) Non-standardized patient groups In-patient vs. pre-hospital Disease states Monitoring/ time to CPR, ALS Small study numbers Challenges in study design retrospective (un-randomized) vs. uncontrolled Failure to match for presenting rhythms Inconsistent definition of dosing HDE/ SDE = same dose via ETT or IV? Poorly defined doses for HDE / SDE Inconsistent entry timing to HDE

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    39. 2007 Stollery PICU Conference

    40. 2007 Stollery PICU Conference Vasopressors and Pediatric CPA: Guidelines 2005 Use epinephrine 0.01 mg/ kg/ dose, with no escalation to high dose epinephrine The pediatric experience with vasopressin for CPA is limited to 1 small case series, 1 case report and some animal data There is insignificant evidence to support/ refute the use of vasopressin for pediatric CPA

    41. 2007 Stollery PICU Conference Drug delivery: Intraosseous (IO) Good literature to show that IO is placed faster and with greater success than peripheral IV access in severely dehydrated children Studies of animals resuscitated from cardiac arrest have shown that whether drugs are delivered via peripheral intravenous, central line (IVC) or tibial IO, plasma epinephrine levels and physiological changes are equivalent Andropoulos, J Peds, 1990, Orlowski, Am J DIs Child, 1990

    42. 2007 Stollery PICU Conference ETT Drug Delivery: Challenges Multiple animal and human studies document erratic/ inconsistent absorption of LEAN drugs ETT dosing of some drugs may be associated with side effects as demonstrated in animal models B-mediated receptor effects (ie. reduced diastolic pressure and coronary artery perfusion) with low doses (0.01-0.02mg/ kg; ie. adult and neonatal guidelines) of ETT epinephrine Efrati, Resuscitation, 2003 Depot effects with prolonged hypertension with ETT epinephrine Mielke, Resuscitation, 2001

    43. 2007 Stollery PICU Conference Guidelines 2005: IO vs ETT Better absorption and drug effect with IO compared to ETT drug delivery Increasing availability of IO devices that are appropriate for all ages, neonates (Ellemunter, Arch Dis Child Fet, 1999) to adults (Iserson, J Emerg Med, 1989; MacNab, PreHosp Emerg Care, 2000) (eg. B.I.G., FAST device) Reduced emphasis on the use of ETT medications (and increased role for IO drug delivery) when traditional venous access unavailable

    44. 2007 Stollery PICU Conference

    45. 2007 Stollery PICU Conference After giving a dose of epinephrine, the rhythm changes and the patient appears to be in ventricular fibrillation. The nurse hands you one of their new biphasic defibrillators. How much electricity do you give? When should you defibrillate? (now or delay?) When should you check for pulse/ rhythm changes?

    46. 2007 Stollery PICU Conference Defibrillation: Whats new?

    47. 2007 Stollery PICU Conference Biphasic Defibrillation Adult data (human and animal) biphasic defibrillation is as successful in electrical conversion and potentially less injurious than monophasic waveform no ROSC benefit (human) Pediatric animal data Biphasic defibrillation is as successful in electrical conversion and is less injurious to the myocardium than monophasic waveforms Biphasic waveforms provide a survival advantage compared to monophasic waveforms in animals no peds human data: extrapolation!! Clark, Resuscitation, 2001, Berg, Circulation, 2004

    48. 2007 Stollery PICU Conference Defibrillation Principles (new for 2005) Time to defibrillation is the most important factor impacting outcome for short (<5 min) CPA in adults (and likely children) with a >5 min CPA, defibrillation is more likely to be successful after a period (2 minutes) of effective chest compressions Wik, JAMA, 2003 Single, not multiple shocks, will be used due to the higher electrical conversion rate with biphasic waveforms, and the shorter period of time without CPR

    49. 2007 Stollery PICU Conference Rhythm after first defibrillation (Biphasic) adultsadults

    50. 2007 Stollery PICU Conference Defibrillation Principles (new for 2005) <5% of defibrillation shocks convert the patient immediately into a perfusing rhythm (pulse-present) Do not do a pulse check immediately following defibrillation! 2 min CPR (ie. Chest compressions) post-defibrillation is appropriate before the next pulse check If a second defibrillation is required, epinephrine should be given at time of 2nd shock (not delaying defibrillation) Eilevstjonn, Resuscitaiton, 2005 On-going CC will not lead to VF recurrence in a patient with spontaneous circulation

    51. 2007 Stollery PICU Conference

    52. 2007 Stollery PICU Conference

    53. 2007 Stollery PICU Conference PALS Changes in Defibrillation 2005 Infants and children needing defibrillation should receive first doses of 2J/ kg (either monophasic or biphasic), with escalation to 4 J/ kg for any further shocks delivered Time to defibrillation is critical for CPA times< 5 min; high quality CPR is critical for reviving longer duration CPAs (2 min CPR ?pre-defib?) Single shocks, immediately followed by 2 minutes CPR (delayed pulse or rhythm checks) are the new standard no CPR interruption for drug delivery!!

    54. 2007 Stollery PICU Conference The nurse gives you a new set of vitals after successful defibrillation HR 190 BPs80 IMV 20 T 39C One of your colleagues suggests that the patient should be cooled for neuro-protection. You scratch your head and think to yourself Where did this come from?

    55. 2007 Stollery PICU Conference Hyperthermia and Outcome after CPA Fever is associated with worse neurological outcome in multiple studies investigating animals and humans (adults) after CPA (epiphenomenon vs. cause?) Fever is commonly observed after CPA in children Hickey, Pediatrics, 2000 Fever control in animals studied after cardiac arrest has been shown to improve neurological outcome No high level evidence in humans

    56. 2007 Stollery PICU Conference Hypothermia: Mechanisms of Protection There is ample experimental data supportive of hypothermic neuroprotection across a range of species (primate, dog, cat, rodent) and injury models (stroke, trauma, global brain ischemia) Reduced cerebral / whole body metabolic rate Direct anti-inflammatory actions Deng Stroke 2003 ???

    57. 2007 Stollery PICU Conference Therapeutic Hypothermia: What does the animal literature tell us? Mild hypothermia (32-34 C) is adequate for neuro-protection in most scenarios Early initiation is more effective than delayed initiation Short duration (<12 h) vs 12-36 h is more likely to delay rather than prevent the evolution of injury.

    58. 2007 Stollery PICU Conference Hypothermia post-VF (OOH) CPA in Adults Note: victims of non-VF CPA (ie. asphyxial CPA, commonly seen in children) were excluded from the trials

    59. 2007 Stollery PICU Conference Hypothermia after Neonatal HIE Gluckman, Lancet, 2005 Multi-centre RCT: cooling of moderate to severely asphyxiated term neonates to 34-35C(r) within 6 hrs of birth for 72 hrs No overall survival/ neuro-outcome benefit (post-hoc subgrp benefit?) Eicher, Pediatr Neurol, 2005 Small pilot multi-centre RCT: cooling of moderate to severely asphyxiated term neonates (clinically defined; not EEG-graded) to 33C(rect) within 6 hrs of birth for 48 hrs Survival and neuro-outcome benefit to hypothermia Shankaran, NEJM, 2005 Multi-centre RCT: cooling of moderate to severely asphyxiated term neonates to 33.5C(eso) within 6 hrs of birth for 72 hrs Significant survival and neuro-outcome benefit to hypothermia

    60. 2007 Stollery PICU Conference Hypothermia: A down side ? Increased incidence of sepsis and pneumonia Clemmer et al, Crit Care Med, 1992 Bohn, Crit Care Med, 1986 Increased incidence of coagulopathy Rohrer et al, Crit Care Med. 1992 Increased incidence of dysrhythmias Fuhrman, Pediatric Critical Care 1992 Risk factor for morbidity/ mortality for: Trauma victims Brun-Buisson JAMA. 1995 Critically ill neonates Racine et al, Helv Paediatr Acta. 1982 All much less common with short periods of moderate hypothermia (32-34C)

    61. 2007 Stollery PICU Conference Post-resuscitation hypothermia and Guidelines 2005 Consider cooling pediatric patients who remain comatose after resuscitation to a temperature of 32-34C for 12 to 24 hours because it may aid brain recovery

    62. 2007 Stollery PICU Conference Induced Hypothermia after Pediatric CPA: What we do not know How quickly to warm? How soon/ late can we warm after injury? How cool do we need to warm to? How long should cooling continue for? How quickly should we rewarm, and to what temperature?

    63. 2007 Stollery PICU Conference Questions?

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    74. 2007 Stollery PICU Conference NRCPR Pediatric CA data (n=880)

    75. 2007 Stollery PICU Conference NRCPR Pediatric CA data (n=880)

    76. 2007 Stollery PICU Conference Pediatric CPA (PICU)

    77. 2007 Stollery PICU Conference How Well Did We Follow The 2000 Guidelines?

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