Pediatric and Neonatal Resuscitation

1. Kristen Johnson Adam Oster Pediatric and Neonatal Resuscitation

2. Objectives • Highlight differences between pediatric and adult cardiac arrest regarding • Etiology • Outcomes • Practice the basics of pediatric resuscitation through a variety of cases • Provide numbers and tips to help in a crunch • Review controversial areas of resuscitation

3. Not little adults?

4. Newly Born – in delivery room, including first few hours of life Newborn – delivery until discharge from hospital/NICU Infant – initial discharge from hospital until 12 months Child – 1 year old until adolescence (signs of puberty) Adult – adolescent (signs of puberty) and older

5. Hypoxemia Hypercapnea Acidosis Bradycardia Hypotension 80% 20%

6. Airway intervention saves 90% IV access saves 9% Drugs save 1%

7. Etiology • Out of Hospital • Trauma (1/3) • Blunt trauma • Drowning • Fire • Residential accidents • Strangulation • Medical (2/3) • SIDS • Respiratory Disease • Cardiac disease/arrhythmia • CNS disease • Toxins • Sepsis • Metabolic Gerein et al. AcadEmerg Med 2006 Young et al. Pediatrics 2004

8. Incidence of Out of Hospital Cardiac Arrest Atkins et al. Circulation 2009

9. Survival Following Out of Hospital Cardiac Arrest Children 9.1% NNT = 10 Adolescents 8.9% NNT = 8 Infants 3.3% NNT = 29 Adults 4.5% NNT = 13 Atkins et al. Circulation 2009

10. VF arrests Occurs in 5% of infants/children 15% of adolescents Survival in VF (20%) >> than PEA/asystole (5%) Mortality increases by 7-10% per minute of delay to defibrillation Atkins et al. Circulation 2009

11. Predictors of increased survival • Peri-arrest • Witnessed arrest* • Weekend arrest • Rhythm other than asystole • No atropine or HCO3 • Fewer epi doses • Shorter duration of CPR • Drowning/submersion* or asphyxial arrest • Post-arrest • Absence of pressors/inotropes • Greater lowest pH • Low lactate • Lower maximum glucose • N pupilllary responses • Higher lowest temperature Moler et al. Crit Care Med 2011 *Donaghue et al. Ann Emerg Med 2005

12. Unresponsive in crib this morning

14. To cuff or not to cuff….  Higher likelihood of correct selection of tube size  No greater risk of post-extubationstridor  May decrease risk of aspiration  Beneficial when high ventilation pressures required Newth et al. J Pediatr 2004 Weiss et al. Br J Anaesth 2009

20. Any role for intratrachealepi? Maybe Probably Not

21. Is there a role for high dose epinephrine?

22. “Less is more…” “There is no survival benefit from high dose epinephrine, and it may be harmful, particularly in asphyxia.” Dieckmann et al. Pediatrics 1995 Carpenter et al. Pediatrics 1997 Perondi et al. NEJM 2004 Patterson et al. PediatrEmerg Care 2005

23. Family presence during resuscitation Patient perspective ??? Family perspective overwhelmingly positive Clinician perspective mixed thoughts

24. Families should be allowed in the resuscitation room. Families Clinicians • Majority want to be present • Most do not regret their decision to be present • Positive trend in psychological health • Less anxiety/depression • Fewer disturbing memories • Eased grief • Family presence does not delay or interfere with care • Procedural performance is not affected • Some have performance anxiety • Some have medical-legal concerns • Nurses > Physicians > Trainees in willingness to include families Tinsley et al. Pediatrics 2008

25. ???When to call it??? • >3 doses of epinephrine • > 30 minutes of CPR in ED • Exceptions: • Primary cardiac disease and • ECMO available • Hypothermia • Suspected toxicologic cause Young et al. Pediatrics 2004 Moler et al. Crit Care Med 2011 Raymond et al. PediatrCrit Care Med 2010 Morris et al. PediatrCrit Care Med 2004

26. Called STAT overhead 18 month old Unwell for 3-4 days Fever Cough resp distress

28. Should we cool our patient? Adults  Neonates  Pediatrics ? Fink et al. PediatrCrit Care Med 2010 Doherty et al. Circulation 2009

29. 7 year old girl Unwell for 1 week Flu-like illness Low grade fever

33. What is the best energy dose for defibrillation? 2 J/kg likely too low 3-5 J/kg may be better No more than 10 J/kg PALS = 2 - 4 J/kg with 4 J/kg for subsequent shocks

34. Anterior-posterior position likely better than Anterior-lateral position Tibballs et al. PediatrCrit Care Med 2011

35. Calcium associated with worse outcomes Survival 21% vs. 44% Favorable neuro outcome 15% vs. 35% Exceptions electrolyte abnormalities toxicological abnormality Srinivasan et al. Pediatrics 2008

36. Bicarbonate not indicated in routine resuscitation • Meert et al. 2009 • Multi-center cohort study that found HCO3 administration associated with increased mortality • Lokesh et al. 2004 • RCT showing no survival benefit in neonates resuscitated with bicarbonate

37. 17 year old brought in from drug house Abdominal pain Thinks may be pregnant

38. 10% of newborns will require some assistance after birth <1% require extensive measures <0.1% require chest compressions

39. < 23 weeks GA Anencephaly Known trisomy 13 Birth weight <400g

40. <29 wk GA Cover with plastic Begin resuscitation with room air

41. M reapply Mask R Reposition head S Suction mouth and nose O Open mouth P increase Pressure A Alternate airway

42. Compression:Breath ratio = 3:1 Terminate after 10 minutes of good CPR

44. THANKS