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Pediatric Resuscitation

Pediatric Resuscitation. Core Rounds Oct 2007 Marc Francis R5 FRCPC PEM Fellow year 1 Dr. 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.

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Pediatric Resuscitation

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  1. Pediatric Resuscitation Core Rounds Oct 2007 Marc Francis R5 FRCPC PEM Fellow year 1 Dr. Roger Galbraith

  2. Objectives • Case based • Challenges • New revisions to ACLS guidelines • Numbers that will help you in a crunch • Pediatric Airway • IV access • Controversies in resuscitation

  3. Personal reading • Neonatal Resuscitation • RSI dosing and drugs for pediatrics • Inotropes and Pressors • Detailed management of specific presentations

  4. 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

  5. Pediatric arrest

  6. 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

  7. 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

  8. 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

  9. 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 Etiologies

  10. Generally, of survivors… Airway intervention saves 90% IV access saves 9% Drugs save 1%

  11. 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….

  12. 2005 ACLS • Simplify resuscitation training and improve the effectiveness

  13. 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

  14. 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

  15. 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 Compression:Ventilation Ratio

  16. 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

  17. Pediatric Chest Compressions • Compress the chest 1/3 – 1/2 its depth • Change compression provider every 2 mins

  18. 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

  19. The Coach comes over and says they have an adult AED inside the nearby arena…. • Do you want to use it?

  20. 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

  21. Shock dose • Biphasic or Monophasic • Initial Shock dose is the same • 2J/kg initially • 4J/kg subsequent

  22. 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???

  23. 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

  24. 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

  25. 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

  26. 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 Case 2

  27. Pediatric Vitals

  28. Heart rate normals >200 is abnormal in any age group >180 is usually abnormal unless in the first year of life

  29. Normal resting RR Newborn 30-60 Infant (1–6 months) 30-50 Infant (6-12 months) 24-46 1-4 yrs 20-30 4-6 yrs 20-25 6-12 yrs 16-20 >12 yrs 12-16 * >60 abnormal in all age groups

  30. Estimate of Minimum Systolic BP AgeMinimal Systolic BP (lowest 5%) 0 – 1 month 60mmHg 1mth – 1year 70mmHg 1yr – 10yrs 70mmHg + 2 (age) >10yrs 90mmHg Less than 60mmHg is always abnormal

  31. Hypotension: LATE! SUDDEN! Compensated vs decompensated shock

  32. 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…..

  33. 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 Numbers that can help in a crunch…

  34. What if you can’t remember doses • Under stressful situations your brain turns to mush… • You stink at math… BROSELOW TAPE!!!!

  35. 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%

  36. 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

  37. A decision is made that the patient requires intubation • What are the issues in intubating a child?

  38. Differences in Peds Airway 1) Big tongue and more soft tissues 2) Narrowest point at subglottis 3) Anterior/cephalad larynx 4) Short trachea 5) Prominent occiput 6) Big floppy epiglottis 7) Higher metabolic rate 8) Lower FRC 9) More compliant chest wall 10) Smaller airway caliber

  39. Anatomical Differences in Peds Airway

  40. 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

  41. 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….

  42. 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

  43. Airway Obstruction • Under 1yo risk of organ damage with abdominal thrusts • Give 5 back blows alternating with 5 chest thrusts • Until relief or unresponsive

  44. Airway Obstruction • Your Abdominal blows are unsuccessful • Other options??? • McGill Forceps • R mainstem intubation of FB • Surgical airway

  45. 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

  46. 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

  47. 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…

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