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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 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


Case study l.jpg
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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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 l.jpg
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


Slide9 l.jpg
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 l.jpg
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 l.jpg
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 l.jpg
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 l.jpg
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 l.jpg
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 l.jpg
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 l.jpg
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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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


Patient profiles l.jpg
Patient Profiles emergency room


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Etiology emergency room


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The Resuscitation emergency room


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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 resuscitation emergency roomGillis, 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 resuscitation emergency roomGillis, 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 l.jpg
    Results of inpatient pediatric resuscitation emergency roomGillis, 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 resuscitation emergency roomGillis, 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 resuscitation emergency roomGillis, 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 resuscitation emergency roomGillis, 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 resuscitation emergency roomGillis, 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 resuscitation emergency roomGillis, 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 resuscitation emergency roomGillis, 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 resuscitation emergency roomGillis, 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 l.jpg
    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 l.jpg
    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 l.jpg
    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 l.jpg
    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 l.jpg
    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 l.jpg
    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 l.jpg
    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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    New Guidelines cardiac arrest

    • amiodarone

    • procainamide

    • lidocaine


    Amiodarone l.jpg
    Amiodarone cardiac arrest

    • 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 l.jpg
    Amiodarone cardiac arrest

    • 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 l.jpg
    Procainamide cardiac arrest

    • 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 l.jpg
    Procainamide cardiac arrest

    • 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 l.jpg
    Lidocaine cardiac arrest

    • 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 l.jpg

    IV, IO cardiac arrest

    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 l.jpg
    Epinephrine cardiac arrest

    • Alpha and beta-adrenergic properties

      • Alpha-adrenergic vasoconstriction

      • Increases aortic diastolic pressure and coronary perfusion


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    High Dose Epinephrine cardiac arrest

    • 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 cardiac arrest

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

    • Higher doses may be considered


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    New Guidelines: Bradycardia cardiac arrest

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


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    New Guidelines: SVT cardiac arrest

    • Vagal maneuvers introduced

    • Verapamil remains contraindicated in infants

    • Amiodarone

    • Procainamide


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    New Guidelines: Stable VT cardiac arrest

    • Amiodarone

    • Procainamide or lidocaine considered alternative agents


    New guidelines pulseless vt vf l.jpg
    New Guidelines: Pulseless VT/VF cardiac arrest

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

    • Epinephrine

    • Amiodarone


    Amiodarone57 l.jpg

    Dose cardiac arrest

    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 l.jpg

    Dose cardiac arrest

    Remarks

    Perfusing Tachycardias

    15 mg/kg IV/IO

    Infuse over 30 – 60 min

    Procainamide


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