Pediatric Cardiac Arrest: Old Evidence and New

GuidelinesTim Lynch, MD

April, 2001

Resuscitation

• Reanimation (Fr)

• Resuscitare (L) – the restoration of life of one apparently dead

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

• 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?

Why do children arrest?

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)

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

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

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

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

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

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)

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

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

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

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

What are the likely outcomes of these children?

Outcome of children who are apneic and pulseless in the emergency room

O’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

Outcome of children who are apneic and pulseless in the emergency room

O’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 ProfilesTotal(34)

Survivors(7)

Nonsurviviors(27)

Age(months)

42.2 35.8 44.3

% < 1 yr 50 28.6 55.6% Male 79.4 100 77.8

EtiologyTotal(34)

Surviviors(7)

Nonsurvivor(27)

SIDS 10 10Infection 4 4A/W Obs 3 1 2

Near-drowning

5 4 1

Abuse 3 1 2Trauma 9 1 8

The ResuscitationSurvivors (7) Nonsurvivors (27)

% Witnessed 42 62

% CPR 86 79

ED Compressions 14 +/- 2.5 16.1 +/1 2.6

% Cardioverted 29 21

PH 6.89 +/- 0.10 6.86 +/- 0.06

Hospital Days 31.4 2.9

Outcome of children who are apneic and pulseless in the emergency room

O’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 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 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 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 resuscitationGillis, J et al. Crit Car Med 1986:14;469-471

Number CPRUnsuccessful

DiedWithin24 h

DiedBeforeDischarge

Respiratory 9 0 2 2

Cardiac 33 15 10 5

Total 42 15 12 7

Results of inpatient pediatric resuscitationGillis, J et al. Crit Car Med 1986:14;469-471

Survived <6 mo

Alive at 6mo

Respiratory 1 4

Cardiac 0 3 (1 withsev neuro)

Total 1 7

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 resuscitationGillis, J et al. Crit Car Med 1986:14;469-471

CPRDuration

Number Diedwithin24 h

Diedbefore

discharge

Alive at6 mo

< 5 min 3 1 1 1

5 – 15min

9 6 1 2

> 15min

21 18 3 0

Results of inpatient pediatric resuscitationGillis, J et al. Crit Car Med 1986:14;469-471

No ofepinephrine

Doses

No ofPatients

CPRUnsuccessful

Died Alive at6 mo

0 16 3 8 5

1 8 2 4 2

2 18 10 8 0

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 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

What’s your dose of epinephrine and why?

High-dose epinephrine improves outcome from pediatric cardiac arrest

Goetting 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)

High-dose epinephrine improves outcome from pediatric cardiac arrest

Goetting 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

High-dose epinephrine improves outcome from pediatric cardiac arrest

Goetting 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

High-dose epinephrine improves outcome from pediatric cardiac arrest

Goetting 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

High-dose epinephrine improves outcome from pediatric cardiac arrest

Goetting 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

High-dose epinephrine improves outcome from pediatric cardiac arrest

Goetting 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

High-dose epinephrine improves outcome from pediatric cardiac arrest

Goetting 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

What are these new agents and when do we use them?

New Guidelines

• amiodarone

• procainamide

• lidocaine

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

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

• 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

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

• 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

HighHighRepeat Doses

0.1 ml/kg 1:10000.1 ml/kg 1:10000

0.1 mg/kg 1:10000.01 mg/kg 1:10000First Dose

HighStandardAsystole/

Pulseless Arrest

ETIV, IO

Epinephrine

• Alpha and beta-adrenergic properties– Alpha-adrenergic vasoconstriction – Increases aortic diastolic pressure and coronary

perfusion

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

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

• Higher doses may be considered

New Guidelines: Bradycardia

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

New Guidelines: SVT

• Vagal maneuvers introduced

• Verapamil remains contraindicated in infants

• Amiodarone

• Procainamide

New Guidelines: Stable VT

• Amiodarone

• Procainamide or lidocaine considered alternative agents

New Guidelines: Pulseless VT/VF

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

• Epinephrine

• Amiodarone

Amiodarone

Infuse over 20-60 min

5 mg/kg IV/IO

(15mg/kg/day)

Perfusing Tachycardias

Bolus

Hypotension

5 mg/kg IV/IOPulseless VF/VT

RemarkDose

Procainamide

Infuse over 30 – 60 min

15 mg/kg IV/IOPerfusing Tachycardias

RemarksDose