Objectives • Understand the causes and management priorities of bradycardia in children. • Identify risk factors for serious causes of syncope in children. • Describe the resuscitation and stabilization of a child presenting with cardiopulmonary failure. • List the strategies for prevention of submersion injuries in infants and children.
Case Presentation • You are called to a suburban home for toddler found submerged in backyard pool. • A sobbing mother is performing CPR on 15-month-old girl on pool deck. • As you take over resuscitation, the mother tells you, “The phone rang; I was only gone for 5 minutes!”
General Assessment: PAT What is your general impression? Appearance Unconscious, unresponsive; poor muscle tone Work of Breathing No spontaneous respirations Circulation to Skin Ashen, cyanosis of hands and lips
General Impression and Management Priorities • General impression: • Sick: respiratory arrest; possible cardiorespiratory failure • Unresponsive, apneic, abnormal circulation to skin • Physiologic problem: global hypoxemic–ischemic event • Immediate management: • Start oxygenation and ventilation while assessing for spontaneous circulation.
Initial Assessment: ABCDEs • Airway — patent • Breathing —good air movement with bag-mask ventilation; wet crackles on auscultation • Circulation — HR 20; femoral pulse barely palpable; capillary refill > 5 seconds; BP not obtained • Disability — pupils dilated, sluggishly reactive; unresponsive to pain • Exposure — no bruises, no signs of injury What is your overall assessment?
Case Progression • Cardiopulmonary failure due to hypoxemia. • Chest compressions are indicated for HR < 60. • No evidence of associated injuries. • Consider spinal injury. • Less likely in toddler submersion than with adolescent diving injury. • Consider nonaccidental trauma. • No “red flags” What are your management priorities?
Management Priorities • BLS: • Place on spine board. • Open airway; begin bag-mask ventilations, 100% 02. • Perform chest compressions. • Dry to prevent further heat loss/hypothermia. • ALS: • IV access, consider endotracheal intubation. • Epinephrine, 0.01 mg/kg IV/IO, or 0.1 mg/kg by endotracheal tube; repeat every 3–5 minutes.
Transport Decision: Stay or Go? • BLS: • Rapid transport to nearest appropriate ED. • Continuous reassessment for return of pulse and circulation en route. • ALS: • Transport after airway/ventilation is secure, IV/IO access is established, and the first dose of epinephrine is given. • Do not delay transport if vascular access fails.
Key Concepts: Bradycardia • Treatable causes of bradycardia with poor perfusion: • Hypoxemia • Hypothermia • Hypovolemia • Heart block • Toxins, poisoning, drugs • Tampondae, cardiac • Tension pneumothorax • Trauma (Head injury)
Key Concepts: Bradycardiawith Submersion Event • Bradycardia in near-drowning reflects significant hypoxia and myocardial ischemia. • The brain and other vital organs may also have suffered ischemic injury. • Rapid support of ventilation and oxygenation will reduce the risk of secondary injury. • The drug of choice is oxygen, followed by epinephrine.
Key Concepts: Drowning Prevention • Pool drowning prevention: • Close supervision • Four-sided pool fence • Self-locking gate • Pool alarms • Open water drowning prevention: • Supervision of all age groups. • Use of personal floatation devices. • Educate teens about dangers of alcohol and water sports. • Risk awareness, as toddler drownings may occur in shallow water.
Key Concepts: Injury Prevention • Multiple strategies are necessary for an effective injury prevention program. • Passive strategies • Legislative action • Enforcement of laws • Education
Case Progression • Oxygen provided by bag-mask device, compressions continued. • After 30 seconds, the heart rate increases to 80 per minute and compressions are discontinued. • After 1 minute, the heart rate is 120 per minute; spontaneous respirations return.
Case Progression • En route: • Supplemental oxygen is delivered by mask. • Blankets are applied to prevent heat loss.
ED Course • In the ED: • The child shows progressive improvement in level of consciousness, asking for her mommy. • She remains hemodynamically stable. • SaO2 is 94% on 100 % O2, and chest X-ray shows diffuse infiltrates. • She is admitted to the pediatric intensive care unit and transferred to a ward the next morning. • Diagnosis: near drowning; pulmonary edema • Outcome: weaned from oxygen on day 2; home on day 4 with normal neurologic exam.
Summary • Submersion results in hypoxia, leading to bradycardia, tissue ischemic injury, and eventually, cardiac arrest. • Early oxygenation and ventilation are the most effective ways to restore spontaneous circulation. • Prehospital management is a major determinant of outcome in children with submersion injury. • Submersion injuries are predictable — prevention is the best treatment!
Case Presentation • You are dispatched to a middle-school athletic field for a child with loss of consciousness. • A 13-year-old boy is lying on the grass, receiving CPR by his coach. • The coach tells you that the child collapsed while running for a ball, and that “this has happened before.” What is the first thing you will do on arrival?
General Assessment: PAT What is your general impression? Work of Breathing No spontaneous respirations Appearance Unresponsive Circulation to Skin Pale, cyanotic
General Impression and Management Priorities • General impression: • Sick: cardiopulmonary failure • Scenario suggests primary cardiac event. • Management: • BLS: apply AED. • ALS: “quick look” on monitor/defibrillator.
Initial Assessment: ABCDEs • Since this was a witnessed collapse, attach the AED as soon as available. • Airway: patent • Breathing: no chest movement • Circulation: absent pulses, no heart sounds; shockable rhythm on AED, ventricular fibrillation (VF) on monitor • Disability: unresponsive to pain • Exposure: no bruising or signs of injury What is your overall assessment?
Case Progression • VF cardiac arrest • Possible mechanisms: • Primary cardiac disease • Trauma (direct blow to precordium) • Toxin/drugs What are your management priorities?
Management Priorities • BLS: • Establish absence of respirations, pulse. • Turn on AED. • Attach AED electrode pads. • Analyze rhythm. • Shock if advised, then resume CPR immediately for five cycles (2 minutes). • If no shock is advised, resume CPR for five cycles (2 minutes). • Check for signs of circulation and rhythm every 2 minutes and repeat sequence from analyze rhythm.
Management Priorities • ALS: BLS priorities plus: • Place on monitor, check rhythm. • Defibrillate. • 2 joules/kg • Resume CPR for five cycles (2 minutes), check rhythm; if VF, defibrillate with 4 joules/kg. • Resume CPR immediately. • Intubate, secure airway (optional). • Obtain vascular access. • Epinephrine 0.01 mg/kg (1:10,000) IV or 0.1 mg/kg ETT (1:1000); repeat every 3-5 minutes. • After five cycles (2 minutes); check rhythm. If shockable: • Defibrillate (4 joules/kg). • Resume CPR immediately. • Consider antiarrhythmic. • Lidocaine 1mg/kg IV/IO/ET • Amiodarone 5 mg/kg IV/IO
Transport Decision: Stay or Go? • Stay on scene and treat until a pulse is established or the child is asystolic. • As in adults, the outcome is strongly linked to resuscitation in the field. • Survival statistics are poor for a child brought to the ED in asystole.
Key Concepts:Ventricular Fibrillation • Airway management and correction of hypoxia while making rhythm diagnosis is critical. • Although pediatric VF is uncommon, early recognition and treatment improve the chance of successful resuscitation. • Early defibrillation increases the survival rate. • Increased availability and use of AEDs in community can improve outcomes for both pediatric and adult VF victims.
Key Concepts:High-risk Groups/Causes for VF • Cardiomyopathies • Coronary artery abnormalities: • Post-Kawasaki disease aneurysms, thrombi • Congenital anomalies • Direct blow to chest • Dysrhythmia syndromes
Key Concept:Identifying Cardiac Syncope • Most fainting spells are benign, but “red flags” can identify serious cardiac causes. • Was the episode associated with chest pain? • Was there a brief or absent aura? • Were there palpitations prior to fainting? • Did it occur during exercise? • Is there a family history of sudden death?
Case Progression • At scene: • Rescue breathing and cardiac compressions started. • AED shows VF — converted to NSR on second shock. • Vascular access obtained • En route: • Lidocaine bolus 1 mg/kg IV and then 20 micrograms/kg/min infusion or bolus every 15 minutes • Continues in sinus rhythm
ED Course • In the ED: • Lead 2 rhythm strip shows QTc = 0.52 • The mother arrives and reports three prior brief episodes of exercise-associated syncope; sudden death at the age of 28 in uncle. • Outcome: child diagnosed with long QTc syndrome. A pacemaker is placed. The patient is discharged neurologically intact 5 days later.
Summary • Most episodes of syncope in children are benign. • Ventricular fibrillation is a rare cause of loss of consciousness in pediatrics. • Early recognition of VF and defibrillation improve survival rates. • When VF is diagnosed, standard cardiac resuscitation protocols should be followed, regardless of the age of the patient.
Summary • The primary cause of cardiopulmonary arrest in children is severe hypoxia associated with respiratory failure. • Asystole or profound bradycardia is the most common arrest rhythm on EMS arrival. • Rapid intervention and return of vital signs in the field are associated with good outcome. • Patients with ventricular fibrillation who have return of sinus rhythm have good survival rates. • Children with asystole as the presenting rhythm on scene rarely survive.