1. Paediatric Resuscitation November 2001

2. contents • epidemiology • eitiologies of arrest – focus on difference between adult and paediatric • ABC’s of peds resuscitation • airway (RSI, LMA’s, etc) • neonatal resuscitation - brief • pediatric cardiac rhythm disturbances • cardioversion/defibrillation/pacing • post recovery care/termination of efforts

3. age definitions • newly born – first hours of life • neonate – first month • infant – neonate to 1 year • child – 1yr – 8yrs • adolescent - >8 yrs

4. epidemiology • CPR is provided for only approximately30% of out-of-hospital pediatric arrests. • survival after cardiac arrest in children averages 7% to 11% • most survivors neurologically impaired • SIDS – 0.8/1000 births

5. eitiology • cause of arrest depends upon • age • location – ie. out-of-hospital vs. in-hospital • pre-existing illness • out-of hospital • trauma, SIDS, drowning, poisoning, choking,severe asthma, and pneumonia • in-hospital • sepsis, respiratory failure, drug toxicity, metabolic disorders,and arrhythmias

6. eitiology • much less likely primarily cardiac • in general… • progression from hypoxia and hypercarbia (respiratory failure) OR shock  respiratoryarrest and bradycardia  asystolic cardiac arrest • therefore – ventilation (CPR) priority over defib (vs. adults) • recognize early respiratory failure and shock prevent arrest

7. eitiology • what about cardiac? • witnessed Sudden collapse • arrythmias • prior hx cardiac disease • congenital prolonged QT • hypertrophic cardiomyopathy • drug overdose • defib priority in these cases

8. airway • chin-lift/jaw thrust • oropharyngeal • Size? central incisor to angle jaw • nasopharyngeal • caution re: secretions, adenoids (difficult insertion or external compression) • laryngeal masks • intubation

9. LMA Zideman D - Ann Emerg Med - 01-Apr-2001; 37(4 Suppl): S126-36 • not studied in infant/child resuscitation • complications more frequent in peds • correct size • 1 = smallest; 3-4 = adult female; 4-5 = adult male • may be dislodged during transport/CPR • aspiration – little protection Gandini D. Neonatal resuscitation with the laryngeal mask airway in normal and low birth weight infants. Anesth Analg. 1999;89:642-3 • case series published in neonates – no patient outcomes

10. intubation • Gerardi MJ. Rapid-sequence intubation of the pediatric patient. Pediatric Emergency Medicine Committee of the American College of Emergency Physicians. Ann Emerg Med - 1996 Jul; 28(1): 55-74

11. pediatric airway - differences • larger head and occiput neck flexion and airway obstruction when the child is supine • relatively larger tongue = less oral space • decreased muscle tone = passive airway obstruction by the tongue • epiglottis shorter, narrower, more horizontal, and softer • larynx anterior  visualization of the cords difficult • trachea is shorter  risk of right main stem intubation • airway is narrower = increased airway resistance • cricoid ring is the narrowest portion of the airway

12. RSI

13. preoxygenation • Basal oxygen use per kilogram per minute in children is greater than that in adults, predisposing the child to a shorter interval before desaturation • 30 seconds – 4 minutes

14. premedication • bradycardia • hypoxia • laryngoscopy (vagal) • meds: sux • atropine indications • <1 yo • 1-5 yo receiving sux • Adolescents receiving 2nd dose sux • dose: 0.02mg/kg (minimum 0.1mg ; max 1mg) • 1-2 minutes prior to intubaton

15. premedication • defasciculation recommended for >5yo • assumption that these patients are at greater risk of the complications of fasciculations because of their larger muscle mass • defasciculation not recommended for <5yo • complications of asystole and bradycardia with succinylcholine

16. sedation • thiopental – can induce bronchospasm (relatively contraindicated in asthmatics) • infants/neonates – more sensitive to fentanyl • fentanyl may increase ICP in children

17. Clinical Scenario Options Normotensive/euvolemic Thiopental, midazolam, propofol Mild hypotension/hypovolemia with head injury Thiopental, etomidate, midazolam Mild hypotension without head injury Ketamine, etomidate, midazolam Severe hypotension Ketamine, etomidate, ½ dose midazolam Status asthmaticus Ketamine, midazolam, propofol Status epilepticus Thiopental, midazolam, propofol Isolated head injury Thiopental, propofol, etomidate Combative patient Midazolam, propofol, thiopental TABLE 3 -- Suggested sedatives for selected clinical situations.

18. paralysis - sux • avoid 2nd dose of sux • infants/children exquisitely sensitive  intractable brady/arrest • recognize limitations to use of sux • hyperkallemia • be aware of possibility of undiagnosed neuro/muscular dz’s • cholinesterase deficiency - 1 in 500 patients • MH - 1 in 15,000 • ICP/IOP • not recommended for non-emergencies

19. paralysis – rocuronium • infants and children • 0.6mg/kg paralysis in 60 seconds • 0.8mg/kg paralysis in 28 seconds • recovery 25% twitch • <10 months old – 45 minutes • 5 years old – 27 minutes • reversal agents • NB. be aware of myopathy with steriods

20. failed intubation • BMV with sellick maneuover • LMA • lighted stylet • retrograde • cricothyroidodomy not recomm. age <8 • complication rate 10-40% • ? Seldinger technique safer ? • transtracheal jet ventilation • surgical method of choice in emergency • allows ventilation for 45-60 mins • risk – aspiration, subcutaneous emphysema, barotrauma, bleeding, catheter dislodgment, CO2 retention

21. intubation • Miller blade or Mac in older • tube size 4 + age/4 • attemptsshould not exceed 30 seconds • bradycardia (<60) • hypoxia • depth of insertion (cm) • tube ID (in mm) x 3. • in children >2 years of age • depthof insertion (cm) = (age in years/2)+12. • direct visualization or breslow • confirm placement – end tidal CO2 etc

22. relative contraindications • evaluated as difficult intubation/difficult ventilation • major facial or laryngeal trauma • upper airway obstruction • distorted facial/airway anatomy • caution in patients who are dependent on their own upper-airway muscle tone or specific positioning to maintain the patency of their airway • paralysis  lose that tone/positioning

23. intubation in pre-hospital setting • Gauche et al. A prospective randomized study of the effect of out-of-hospital pediatric endotracheal intubation on survival and neurological outcome. JAMA. 2000;283:783–790. • endotracheal intubation may not improvesurvival over bag-mask ventilation in all EMS systems • endotrachealintubation appears to result in increased airway complications

24. breathing • signs of respiratory failure/impending arrest • increased respiratory rate • distress/increased respiratoryeffort • inadequate respiratory rate, effort, or chest excursion • diminished breath sounds • gasping or grunting respirations • decreasedlevel of consciousness or response to pain • poor skeletal muscletone • cyanosis

26. circulation • signs of circulatory comprimise • heart rate – tachycardia or bradycardia (pre-arrest) • presence and volume (strength)of peripheral pulses • adequacy of end-organ perfusion • mental status • capillary refill • skin temperature • urine output (>1cc/kg infant/child; >30cc/hr adolescent) • metabolic acidosison laboratory evaluation

27. circulation • hypotension definitions • term neonates (0 to 28 days of age), SBP <60 mm Hg • infants from 1 month to 12 months, SBP <70 mm Hg • children>1 year to 10 years, SBP <70+(2xage in years) • heyond10 years, SBP <90 mmHg • NB. remember – hypotension is late finding in shock suggesting impending arrest

28. CPR • chest compressions with backboard • two handed in infants • internal cardiac massage not recommended • chest wall compliance

29. vascular access • peripheral • interosseous • anteriortibial bone • distal femur, medial malleolus, ASIS, ?ulna/radius • central vein (femoral, ext/int jugular) • femoral prefered • catheter length • Infants – 5cm • “young” child – 8 cm • “older” child – 12 cm • intra-tracheal – “LEAN” drugs (lipid soluable)

30. interosseous • all drugs, fluids ok • may need increased pressure of infusion • ?increased risk fat emboli • can draw bloodwork • caution with bicarb infusion and interpreting MVO2 • complications: fracture,compartment syndrome, osteomyelitis, extravasation

31. fluids • NS, LR • blood • refractory shock to 40-60cc/kg crystalloid • no evidence for colloid or HTS

32. neonatal resuscitation • infrequent event in ER • preparation • anticipate problems • get help • O2 source/BVM/intubation supplies (laryngoscope/ET tube/suction adapter) • suction catheter • warmer/dry warm linen • medications

33. neonatal resuscitation • steps • 1. under warmer • 2. suction trachea if meconium • 3. dry • 4. remove wet linen • 5. position • 6. suction mouth then nose • 7. tactile stimulation

34. neonatal resuscitation • 1. evaluate respiration • none/gasping  PPV 15-30seconds  HR • spontaneous  HR • 2. evaluate HR • <60  PPV, CP • 60-100 not increasing  PPV, CP if HR<80 • 60-100 increasing  PPV • >100  observe for spontaneous resp • 3. HR after 30s <80  initiate meds • 4. evaluate color  blue?  supplemental O2

35. meconium • 10-20% of all deliveries • intervention only with thick, particulate stained amniotic fluid • suction when head delivered and on warmer • 10 french suction catheter; 100 mm Hg • Depth mouth to ear • direct visualization of glottis and suction below cords • ET tube with suction adapter

36. rhythm disturbances • most often consequence not cause of arrest • correct underlying causes • most asystolic or brady arrest • 10-20% pulseless VT/VF • Proportion increases with age

37. bradyarrhythmias • eitiologies • hypoxemia, hypothermia, acidosis, hypotension, and hypoglycemia • vagal stimulation (intubation, suctioning) • CNS/ICP • toxicology • significant if • hemodynamic instability • <60 bpm • rapid decrease in HR despite oxgenation, vent, perf

38. bradyarrhythmias • treatment • epinephrine for hypotension/poor perfusion • primarily treatment of choice • atropine for vagal mediated, heart blk • pacing for heart blk • refractory?  epi or dopamine infusion

39. transcutaneous pacing • < 15kg  paediatric electrodes • > 15kg  adult • positioning • anterior (+) – posterior (-) • R infraclavicular (+) – L midaxillary 4th ICS (+)

40. PEA • often represents apreterminal condition that immediately precedes asystole • frequently represents the final organized electrical state ofa severely hypoxic, acidotic myocardium

41. PEA • hypovolemia • hypoxemia • hypothermia • hyperkalemia • tension pneumothorax • pericardial tamponade • toxins • pulmonarythromboembolus

42. PEA • oxygenate • ventilate • CPR • fluid resuscitate • epinephrine • special interventions

43. tachycardia • narrow complex • SVT – most common arrythmia • sinus tachycardia • wide complex • abberancy – uncommon • VT/VF

44. SVT most often narrow abberent conduction uncommon HR >220 HR >180 abrupt onset/offset Sinus tachycardia narrow complex HR < 220 infants HR <180 children aariable/slow onset/offset look for cause (hypovolemia, fever, etc) SVT vs sinus tachycardia

45. SVT - options • unstable? cardioversion 0.5-1.0 J/kg • vagal maneuvers • adenosine 0.1 mg/kg – repeat 0.2 mg/kg • avoid verapamil in infants • refractory hypotension and cardiac arrest • verapamil in children (>1yr) – 0.1mg/kg • amiodarone • procainamide

46. ventricular arrhythmias – VT/VF • uncommon in children • eitiology • congenital heart dz, cardiomyopathy, myocarditis • reversable causes • metabolic (hyperK,hyperMg, hypoCa, hypoglyc) • drug toxicity • hypothermia

47. VT • stable – options • amiodarone- 5 mg/kg over 20 to 60 minutes • procainamide - 15 mg/kg over 30 to 60 minutes • lidocaine - 1 mg/kg over 2 to 4 minutes • followed by 20 to 50 µg/kg per minute • unstable • cardioversion – 2-4 J/kg

48. pulseless VT/VF • defibrillation – 2-4J/kg • ventilation, oxygenation, fluid resusc • epinephrine • shocks • shock resistant (ie. >4)? • amiodarone 5mg/kg (max 15mg/kg/day)

49. cardioversion/defibrillation • paddle size • >1yr >10kg  adult paddles/pads • <1yr <10kg  infant paddles/pads • placement • both anterior (right upper/apex) • anterior-posterior • paddles/pads/gel should not touch each other

50. cardioversion/defibrillation • cardioversion 0.5j/kg, 1j/kg, 2j/kg • defib <8yo = 2 j/kg, 4 j/kg, 4 j/kg • defib >8yo, > 50kg = 200, 300, 360 • AED’s > 8yo • ?biphasic - >8yo >25kg