Pediatric Resuscitation

Core Rounds Oct 2007Marc Francis R5 FRCPCPEM Fellow year 1Dr. Roger Galbraith

Objectives

• Case based

• Challenges

• New revisions to ACLS guidelines

• Numbers that will help you in a crunch

• Pediatric Airway

• IV access

• Controversies in resuscitation

Personal reading

• Neonatal Resuscitation

• RSI dosing and drugs for pediatrics

• Inotropes and Pressors

• Detailed management of specific presentations

Challenges of Pediatric Resuscitation

• Emotional • Lack of patient verbal skills• Patient fear• Varying normal values for vital signs• IV access• Drug dosing• Technical skills more challenging• Parental presence

Pediatric arrest

• Comprehensive review 1966 – 2004• 5363 pts in 41 different studies

• 12.1% survived to hospital discharge• 4% survived neurologically intact

• Better outcomes with• Trauma arrest• Submersion injury

• Improved survival with• Witnessed arrest• Bystander CPR

• Prospective observational study from a registry of cardiac arrests

• The rate of survival to hospital discharge following pulseless cardiac arrest was higher in children than adults:

27% (236/880) vs 18% (6485/36,902)adjusted OR = 2.29, 95%CI (1.95-2.68)

• Of these survivors 65% of children and 73% of adults had good neurological outcome

• First documented pulseless arrest rhythm was typically asystole or PEA in both children and adults

• Survival to hospital discharge with asystole and PEA was:– 24% in the children (135/563)– 11% in the adults (2719/24,987) – OR 2.73 (2.23-3.32)

• Children had better outcomes than adults despite fewer cardiac arrests due to VF or pulseless VT

Etiologies

Out-of-hospital• SIDS• Trauma (most

common > 6 months)• Submersion• Sepsis• Cardiac diagnosis• Pulmonary disease

In-hospital• Sepsis• Respiratory failure• Drug toxicity• Metabolic disorders• Arrhythmias

Generally, of survivors…

Airway intervention saves 90%

IV access saves 9%

Drugs save 1%

Case 1

• You are at your daughter’s soccer game enjoying a cold one

• There is a large commotion on another pitch and they call for help

• A 4yo M suddenly collapsed on the field and is not breathing

• You rush to his side and find him to be apneic and pulseless….

2005 ACLS

• Simplify resuscitation training and improve the effectiveness

Caveats…

• Most pediatric ACLS recommendations are “class indeterminate”

• Promising but low-level evidence or high-level but inconsistent evidence

• Extrapolation from adult evidence

• None are “class I”• At least one RCT with excellent critical assessment

and positive, homogeneous results

2005 ACLS Key Points

• Push hard and fast• Chest compressions at rate of 100/min

• Limit interruptions in chest compressions• Universal compression to ventilation ratio

• 30:2 for all lone rescuers

• Each breath should be delivered over 1 second• Attempted defibrillation than immediate CPR

Compression:Ventilation Ratio

Single Provider

• Universally 30:2 for all age groups for single provider CPR except neonates

2 Provider CPR• 30:2 for adult 2

providers• 15:2 for infants and

children two providers• Continuous

compressions when advanced airway in place at 8-10 bpm

Pediatric Chest Compressions

• Rescuers may use 1 or 2 hands to give chest compressions– Children >1yo

• press at the nipple line

– Infants <1yo• Press just below the nipple line

• Use 2 fingers for compression in lone CPR

• 2 thumb encircling technique for 2-provider CPR

Pediatric Chest Compressions

• Compress the chest 1/3 – 1/2 its depth

• Change compression provider every 2 mins

• Mannekin based study with 40 subjects • Compressions at 100/min for 2 consecutive periods of

3mins with 30 seconds rest in between• Number of satisfactory chest compressions performed

decreased progressively during resuscitation (p< 0.001) • First min = 82/min• Second min = 68/min• Third min = 52/min• Fourth min = 70/min• Fifth min = 44/min• Sixth = 27/min

• Effect was greater in female providers• Providers did not perceive their own fatigue

• The Coach comes over and says they have an adult AED inside the nearby arena….

• Do you want to use it?

AEDs in Children

• Recommended for children ≥ 1 year old– In out of hospital arrest use the AED after 5 cycles of

CPR (~2 mins)

– If the available AED does not have child pads can use a regular AED with adult pads

• Evidence is insufficient to recommend for or against the use of AEDs in infants under 1 year of age– Class Indeterminate

Shock dose

• Biphasic or Monophasic

• Initial Shock dose is the same– 2J/kg initially– 4J/kg subsequent

Case 1 con’t

• The AED shows Asystole and no shock is delivered.

• Paramedics arrives on scene and 3 rounds of Epi with good CPR are administered with no effect

• The Medic asks you if he should try high dose epinephrine???

• Retrospective cohort study comparing high dose epi to standard epi in OOHCA

• N= 65 pts <18yo– 40pts (62%) HDE– 13pts (20%) SDE

• Outcome measures• ROSC• Return of organized electrical activity• Hospital admission• Hospital discharge• Neuro outcomes

• HDE did not improve the rates of any of the outcomes

High dose Epinephrine

• High dose Epi = 0.1mg/kg IV/IO– Routine use has never shown a survival benefit – May be harmful particularly in asphyxia

• Currently is not recommended routinely– Class III evidence

• Considered only in exceptional circumstances such as B-blocker overdose

Case 2

• 13 month old Male. Attends daycare. • Diagnosed with “reactive airways” in the

past• Mother has ventolin puffer he rarely uses• Runny nose and cough for 3 days• Then marked respiratory distress noted last

24hrs and no po intake• Taken to resuscitation room

Case 2

• Vitals – T 38.2 °C

– HR 179

– RR 56

– BP 81/56

– Sat 88% on RA

– Chemstrip 4.6

• Even before you examine the child….

• What is your impression of the vital signs

Pediatric Vitals

Heart rate normals

>200 is abnormal in any age group>180 is usually abnormal unless in the first year of

life

Normal resting RR

Newborn 30-60Infant (1–6 months) 30-50Infant (6-12 months) 24-461-4 yrs 20-304-6 yrs 20-256-12 yrs 16-20>12 yrs 12-16

* >60 abnormal in all age groups

Estimate of Minimum Systolic BP

Age Minimal Systolic BP

(lowest 5%)

0 – 1 month 60mmHg

1mth – 1year 70mmHg

1yr – 10yrs 70mmHg + 2 (age)

>10yrs 90mmHg

Less than 60mmHg is always abnormal

Hypotension: LATE! SUDDEN!

Compensated

vs

decompensated

shock

Case 2 Continued

• Generally: – looks unwell, pale and in marked distress

• CVS: – Tachy, normal HS, cap refill 4 secs, normal pulses

• Resp: – Tachypneic, suprasternal and scalene retractions, silent

chest• During next 5 mins patient becomes more drowsy

and lethargic with apneic periods• What do you want to do now…..

Numbers that can help in a crunch…

• Estimate of weight:= 8 + 2 (age)

• SBP lowest 5% = 70 + 2 (age)

• Estimate of tube size:= age / 4 + 4

• Depth of ETT insertion:= ETT Size x 3

• Foley catheter size= ETT size x2

• NG tube size= ETT size x 2

• Chest Tube size = ETT size x 4

What if you can’t remember doses

• Under stressful situations your brain turns to mush…

• You stink at math…

BROSELOW TAPE!!!!

• Examined 7500 kids in Ohio• Compared actual weight to predicted weight

by the Broslow• Broslow colour predicted by height vs

actual weight– Overall percentage agreement 66.2%– Overall Kappa value was 0.61

• Accurately predicted ETT size in 71%

• Tape accurately predicted medication doses within 10% in 55-60% of patients

• Kids were under dosed (by ≥10%) 2.5 to 4.4 times more often than those over dosed (by ≥10%) p<0.05

• Concluded that the Broselow tape inaccurately predicts weight in up to 1/3 of North American kids and could result in underresuscitation

• A decision is made that the patient requires intubation

• What are the issues in intubating a child?

Differences in Peds Airway

1) Big tongue and more soft tissues2) Narrowest point at subglottis3) Anterior/cephalad larynx4) Short trachea5) Prominent occiput6) Big floppy epiglottis7) Higher metabolic rate8) Lower FRC9) More compliant chest wall10) Smaller airway caliber

Anatomical Differences in Peds Airway

To cuff or not to cuff….that is the question

• Cuffed endotracheal tubes may be used in infants (except newborns) and children in in-hospital settings provided that cuff inflation pressure is kept <20 cm H2O

• One randomized controlled trial 3 prospective cohort studies and 1 cohort study document no greater risk of complications in children < 8yo

• Khine HH, Corddry DH, Kettrick RG, et al. Comparison of cuffed and uncuffed endotracheal tubes in young children during general anesthesia. Anesthesiology. 1997;86:627–631

Case 3

• 3yo M• Sucking on large jaw breaker candy and

onset of choking• EMS called and currently on-route to ACH• Initially coughing and wheezing• 2 mins out patch saying has become

cyanotic, silent and apneic• Unresponsive and weak pulse on arrival….

Airway Obstruction

• Signs of severe airway obstruction– Poor air exchange

– Increased breathing difficulty

– Silent cough

– Cyanosis

– Inability to speak or breath

• Children ≥ 1yo– Abdominal thrust

• Infants ≤ 1yo– Back slaps

– Chest thrust

Airway Obstruction

• Under 1yo risk of organ damage with abdominal thrusts

• Give 5 back blows alternating with 5 chest thrusts• Until relief or unresponsive

Airway Obstruction

• Your Abdominal blows are unsuccessful

• Other options???

• McGill Forceps

• R mainstem intubation of FB

• Surgical airway

Pediatric Surgical Airway

• Cricothyroidotomy– Extremely difficult in kids <10yo (Almost

impossible)– Too small an anatomical space for Seldinger kit– Often Cricoid cartilage is the narrowest portion

so does not bypass the obstruction

Pediatric Surgical Airway

• Transtracheal jet ventilation– 10 gauge needle or 14 gauge angiocath

– Standard wall source of O2

– Placed at the cricothyroid membrane or between the tracheal rings inferior to the cricoid cartilage

– 3cc Syringe with plunger removed and a 90° angle piece connected to an ambibag for kids <5yo

– Pressurized Jet Ventilator for kids >5yo

Case 3 Continued

• You successfully transtracheal ventilate the patient below the obstruction and get good chest rise and return of Oxygenation

• The patient remains in PEA…

Case 4

• 14yo healthy Male• Motorcycle at 70km/hr hit the back of a

stationary truck • Wearing Helmet• Initially unconscious on scene and blood in

airway• EMS arrival has agonal respirations and

then stops breathing….

Case 4

• On STARS arrival patient receiving CPR and BVM ventilation

• PEA on the monitor

• Obvious facial trauma and bilateral UE fractures

• Distended abdomen with periumbilical bruising

Case 4

• Bilateral needle decompression performed

• Successful crash ETT placed

• Attempts x 2 by STARS medical crew for IV line with no success

• Monitor continues to show organized electrical activity but pulseless….

IV access in Peds

• Few things cause more distress to non-pediatric trained resuscitators

• Infants have small veins and often lots of SC tissues

• Even more difficult in the sick child or infant who is hypovolemic and peripherally shut down

Vascular Access

• Peripheral IV• Technically easy

• Difficult in small children

• Peripherally shut down

• Rate limited flow

• Central line• Technically challenging and time consuming

• Femoral, Internal jugular, Subclavian

• Larger bore

• Interosseous (IO)

The secret vein only anesthesia seems to know about…

• Great Saphenous Vein at the foot

• Consistently found just anterior to the medial malleolus

• May not be visible at surface

• Large vein which is easily cannulated

Interosseous• Useful in all ages• Previous recommendation was

after 90 seconds of attempts for PIV– Now recommendation is

immediately• Allows for

• Fluids• Drugs• Bloodwork

• Technically easy• Complications

– Compartment– Infection

ETT drug administration

• Administration of drugs into the trachea results in lower blood concentration than the same dose given by IV/IO route

• Recent animal studies – Show that the lower epinephrine concentrations

achieved when the drug is delivered by the endotracheal route may produce transient β-adrenergic effects.

– These effects can be detrimental, causing hypotension, lower coronary artery perfusion pressure and flow, and reduced potential for ROSC

Case 4 continued

• You get an IO running and after fluid resuscitation with 1 liter of NS and 1 round or Epi you get a pulse back

• The patient is transported to the ACH and remains comatose

• The ICU resident asks you if you think we should cool the patient???

Hypothermia ACLS

• Induced hypothermia may be considered if the child remains comatose after resuscitation– 32ºC to 34ºC for 12 to 24 hours – Class IIb Evidence– Extrapolated from Adult data

• The 2005 guidelines emphasize the importance of avoiding hyperthermia

• Providers should monitor temperature and treat fever aggressively– Class IIb Evidence

Case 5

• 4yo M 15kg• Known prior allergy to

bee stings• Stung today at school• Mother has Epi pen in

a drawer at home• EMS arrives with him

at the ACH…

Exam

• Markedly swollen face and eyes

• Lips and uvula swollen

• Stridor noted• Diffuse wheeze• BP 70/51• What would you like

to do?

Epi dosing in pediatrics

• Dose is always 0.01mg/kg

• In Anaphylaxis use 1:1000 epinephrine IM– This is 1mg/ml =

0.01ml/kg IM • 10kg = 0.1ml

• 20kg = 0.2ml

• 30kg = 0.3ml

• In Resuscitation use 1:10,000 epinephrine IV/IO– This is 0.1mg/ml =

0.1ml/kg IV/IO• 10kg = 1ml

• 20kg = 2ml

• 30kg = 3ml

Case 6

• 8 month old male• Found unresponsive and blue by parents at 0600

in the morning• EMS called and patch in indicating they are 5

mins out with Asystole on the monitor and doing CPR

• Unable to get IV access• You are preparing the trauma room and the team

for arrival of the patient….

Case 6

• Patient arrives in asystole with no signs of life

• The nurse gets an IV line and you administer Epinephrine and Atropine IV followed by 1 minute of good CPR

• There is no response…

• What now?

When to quit?

• Prospective study of 300 kids in CPA• No survivor received epinephrine

Sirbaugh et al. Annals of Emerg Med 1999. 33(174)

• 101 kids with CPA or resp arrest• No survivors needed resuscitative efforts for more

than 20 minutes or > 2 doses of epinephrineSchindler et al. New Eng J Med 1996. 335(1473-79)

Termination of efforts

• Multiple other studies– Small sample sizes, heterogeneous populations,

retrospective designs, etc

– Some survival despite prolonged resuscitation

– Difficult to draw any firm conclusions

• Very little consensus in the literature to guide you• PEA and Asystole may not carry the same

prognosis in peds as it does in adults

Current ACLS guidelines

• If a child fails to respond to two doses of epinephrine with a ROSC the child is unlikely to survive

• Resuscitative efforts may be ceased in pediatric CPA victims after 30 minutes unless exceptional circumstances exist

i.e.• primary hypothermic insult• toxic drug exposure• recurrent or refractory VF/VT

• Cross sectional survey– 160 PEM (70%)

– 127 GEM (62%)

• PEM were >2x more likely to terminate resuscitative efforts if ROSC was not achieved by 25 mins

Case 6

• You administer a 2nd round of epinephrine with no effect and then ask if anyone has any other suggestions

• After 20mins of efforts you call the resuscitation and note the time of death

• The family members who have been present during the resuscitation are screaming for you to try and do something else

• They want to take the baby to another hospital hoping that they will be able to try something….

Family Presence during resuscitaiton

• Traditionally family members were excluded • The concept of family-centered care in the ED has

now become more widespread• Overwhelmingly family members are in favour or

being present• ED staff opinion has been mixed• Many organizations now endorse family presence

• Extensive Review of the ED literatureConclusions:

1) Family presence should be an option for routine invasive procedures in the ED

2) Family presence should be an option for critical resuscitation and CPR in the ED

3) All members of the resuscitation team must be in agreement 4) Dedicated medical interpreter should accompany the patient5) If family leaves during a critical phase of the resuscitation all

efforts should continue until family returns to allow final moments with their dying child

6) Institutions should have guidelines7) Trainees should be provided with skills and experience in

functioning under parental presence

Pediatric Death in ED

• No formal training in coping with pediatric deaths • With ED death there is usually no established

relationship with the parents• Viewed as particularly tragic with strong emotions

– Children aren't supposed to die

– It's not natural

– The child never had an opportunity to experience a full life

Pediatric Death in ED

CRISIS• Powerful and often

uncontrollable emotions • Illogical or impaired

decision-making abilities • Recruiting other team

members and family members for support

GRIEF• Begins with understanding

that the child's death is real

• Allow (not force) family members to see or hold their dead child

• Prepare them for what they may see

• Opportunity to take a momento

Pediatric Death in ED

• Address family feelings of guilt• Reassure families that they did not contribute (either by acts of

commission or omission) to the child's death

• Reassure families that every care procedure that could have been implemented in the ED was implemented is important

• Health team debriefing – Strengths and weaknesses of the resuscitation

– Each team member can have an opportunity to ask questions or offer comments

Questions?