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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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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
slide9
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
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
slide17

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
slide28
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 (+)
slide40
PEA
  • often represents apreterminal condition that immediately precedes asystole
  • frequently represents the final organized electrical state ofa severely hypoxic, acidotic myocardium
slide41
PEA
  • hypovolemia
  • hypoxemia
  • hypothermia
  • hyperkalemia
  • tension pneumothorax
  • pericardial tamponade
  • toxins
  • pulmonarythromboembolus
slide42
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
slide47
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?