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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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resuscitation
Resuscitation
  • Reanimation (Fr)
  • Resuscitare (L) – the restoration of life of one apparently dead
case study
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.
case study questions objectives
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?
slide6
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)
slide7
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
slide8
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
slide9
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
slide10
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
slide11
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
slide12
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)
slide13
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
slide14
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
slide15
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
slide16
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
slide18
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
slide19
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
slide23
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
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
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)
results of inpatient pediatric resuscitation gillis j et al crit car med 1986 14 469 47126
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 47129
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 47132
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
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
slide35
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)
slide36
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
slide37
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
slide38
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
slide39
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
slide40
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
slide41
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
new guidelines
New Guidelines
  • amiodarone
  • procainamide
  • lidocaine
amiodarone
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
amiodarone45
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
procainamide
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
procainamide47
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
lidocaine
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
pediatric epinephrine dosing

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
epinephrine
Epinephrine
  • Alpha and beta-adrenergic properties
    • Alpha-adrenergic vasoconstriction
    • Increases aortic diastolic pressure and coronary perfusion
high dose epinephrine
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
new guidelines epinephrine
New Guidelines: Epinephrine
  • The conventional dose of epinephrine is recommended for second and subsequent doses
  • Higher doses may be considered
new guidelines bradycardia
New Guidelines: Bradycardia
  • Atropine is recommended in the treatment of symptomatic bradycardia caused by AV block or increased vagal tone
new guidelines svt
New Guidelines: SVT
  • Vagal maneuvers introduced
  • Verapamil remains contraindicated in infants
  • Amiodarone
  • Procainamide
new guidelines stable vt
New Guidelines: Stable VT
  • Amiodarone
  • Procainamide or lidocaine considered alternative agents
new guidelines pulseless vt vf
New Guidelines: Pulseless VT/VF
  • Defibrillation 2 J/kg, 4 J/kg, 4 J/kg
  • Epinephrine
  • Amiodarone
amiodarone57

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
procainamide58

Dose

Remarks

Perfusing Tachycardias

15 mg/kg IV/IO

Infuse over 30 – 60 min

Procainamide