Paediatric Resuscitation

1
Paediatric Resuscitation

• November 2001

2
contents

• epidemiology
• eitiologies of arrest focus on difference
  between adult and paediatric
• ABCs of peds resuscitation
• airway (RSI, LMAs, etc)
• neonatal resuscitation - brief
• pediatric cardiac rhythm disturbances
• cardioversion/defibrillation/pacing
• post recovery care/termination of efforts

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age definitions

• newly born first hours of life
• neonate first month
• infant neonate to 1 year
• child 1yr 8yrs
• adolescent - gt8 yrs

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epidemiology

• CPR is provided for only approximately 30 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

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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

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eitiology

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

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eitiology

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

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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

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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. 199989642-3
• case series published in neonates no patient
  outcomes

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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

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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

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RSI
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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

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premedication

• bradycardia
• hypoxia
• laryngoscopy (vagal)
• meds sux
• atropine indications
• lt1 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

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premedication

• defasciculation recommended for gt5yo
• assumption that these patients are at greater
  risk of the complications of fasciculations
  because of their larger muscle mass
• defasciculation not recommended for lt5yo
• complications of asystole and bradycardia with
  succinylcholine

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sedation

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

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TABLE 3 -- Suggested sedatives for selected
clinical situations.

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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 dzs
• cholinesterase deficiency - 1 in 500 patients
• MH - 1 in 15,000
• ICP/IOP
• not recommended for non-emergencies

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paralysis rocuronium

• infants and children
• 0.6mg/kg paralysis in 60 seconds
• 0.8mg/kg paralysis in 28 seconds
• recovery 25 twitch
• lt10 months old 45 minutes
• 5 years old 27 minutes
• reversal agents
• NB. be aware of myopathy with steriods

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failed intubation

• BMV with sellick maneuover
• LMA
• lighted stylet
• retrograde
• cricothyroidodomy not recomm. age lt8
• 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

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intubation

• Miller blade or Mac in older
• tube size 4 age/4
• attempts should not exceed 30 seconds
• bradycardia (lt60)
• hypoxia
• depth of insertion (cm)
• tube ID (in mm) x 3.
• in children gt2 years of age
• depth of insertion (cm) (age in years/2)12.
• direct visualization or breslow
• confirm placement end tidal CO2 etc

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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

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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. 2000283783790.
• endotracheal intubation may not improve survival
  over bag-mask ventilation in all EMS systems
• endotracheal intubation appears to result in
  increased airway complications

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breathing

• signs of respiratory failure/impending arrest
• increased respiratory rate
• distress/increased respiratory effort
• inadequate respiratory rate, effort, or chest
  excursion
• diminished breath sounds
• gasping or grunting respirations
• decreased level of consciousness or response to
  pain
• poor skeletal muscle tone
• cyanosis

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(No Transcript)
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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 (gt1cc/kg infant/child gt30cc/hr
  adolescent)
• metabolic acidosis on laboratory evaluation

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circulation

• hypotension definitions
• term neonates (0 to 28 days of age), SBP lt60 mm
  Hg
• infants from 1 month to 12 months, SBP lt70 mm Hg
• children gt1 year to 10 years, SBP lt70(2xage in
  years)
• heyond 10 years, SBP lt90 mm Hg
• NB. remember hypotension is late finding in
  shock suggesting impending arrest

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CPR

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

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vascular access

• peripheral
• interosseous
• anterior tibial 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)

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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

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fluids

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

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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

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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

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neonatal resuscitation

• 1. evaluate respiration
• none/gasping ? PPV 15-30seconds ? HR
• spontaneous ? HR
• 2. evaluate HR
• lt60 ? PPV, CP
• 60-100 not increasing ? PPV, CP if HRlt80
• 60-100 increasing ? PPV
• gt100 ? observe for spontaneous resp
• 3. HR after 30s lt80 ? initiate meds
• 4. evaluate color ? blue? ? supplemental O2

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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

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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

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bradyarrhythmias

• eitiologies
• hypoxemia, hypothermia, acidosis, hypotension,
  and hypoglycemia
• vagal stimulation (intubation, suctioning)
• CNS/ICP
• toxicology
• significant if
• hemodynamic instability
• lt60 bpm
• rapid decrease in HR despite oxgenation, vent,
  perf

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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

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transcutaneous pacing

• lt 15kg ? paediatric electrodes
• gt 15kg ? adult
• positioning
• anterior () posterior (-)
• R infraclavicular () L midaxillary 4th ICS ()

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PEA

• often represents a preterminal condition that
  immediately precedes asystole
• frequently represents the final organized
  electrical state of a severely hypoxic, acidotic
  myocardium

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PEA

• hypovolemia
• hypoxemia
• hypothermia
• hyperkalemia
• tension pneumothorax
• pericardial tamponade
• toxins
• pulmonary thromboembolus

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PEA

• oxygenate
• ventilate
• CPR
• fluid resuscitate
• epinephrine
• special interventions

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tachycardia

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

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SVT vs sinus tachycardia

• SVT
• most often narrow
• abberent conduction uncommon
• HR gt220
• HR gt180
• abrupt onset/offset

• Sinus tachycardia
• narrow complex
• HR lt 220 infants
• HR lt180 children
• aariable/slow onset/offset
• look for cause (hypovolemia, fever, etc)

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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 (gt1yr) 0.1mg/kg
• amiodarone
• procainamide

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ventricular arrhythmias VT/VF

• uncommon in children
• eitiology
• congenital heart dz, cardiomyopathy, myocarditis
• reversable causes
• metabolic (hyperK,hyperMg, hypoCa, hypoglyc)
• drug toxicity
• hypothermia

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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

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pulseless VT/VF

• defibrillation 2-4J/kg
• ventilation, oxygenation, fluid resusc
• epinephrine
• shocks
• shock resistant (ie. gt4)?
• amiodarone 5mg/kg (max 15mg/kg/day)

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cardioversion/defibrillation

• paddle size
• gt1yr gt10kg ? adult paddles/pads
• lt1yr lt10kg ? infant paddles/pads
• placement
• both anterior (right upper/apex)
• anterior-posterior
• paddles/pads/gel should not touch each other

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cardioversion/defibrillation

• cardioversion 0.5j/kg, 1j/kg, 2j/kg
• defib lt8yo 2 j/kg, 4 j/kg, 4 j/kg
• defib gt8yo, gt 50kg 200, 300, 360
• AEDs gt 8yo
• ?biphasic - gt8yo gt25kg

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pharmacology - epinephrine

• epinephrine
• 0.01mg/kg (110 000) q3-5 min during arrest
• 0.1mg/kg (11000) intratracheal
• 0.1-0.2mg/kg (11000) high dose not recommended

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pharmacology - atropine

• atropine
• 0.02 mg/kg
• minimum 0.1 mg lt paradoxical brady
• max 0.5mg in child x2 1mg in adolescent x2

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pharmacology vasopressin

• Vasopressin
• systemic vasoconstriction
• selective vasoconstriction of skin, skeletal
  muscle, intestine, and fat
• relatively less vasoconstriction of coronary,
  cerebral, and renal vascular beds
• reabsorption of water in the renal tubule
• Not studied in paediatric arrest not recommended

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pharmacology - calcium

• calcium chloride
• 0.2 mL/kg of 10 calcium chloride
• slow infusion 20secs in arrest 10 mins in
  perfusing rhythm
• indications
• hypocalcemia
• hypermagnesemia
• ?PEA ?asystole not recommended

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pharmacology - magnesium

• 25-50 mg/kg
• indications
• torsades
• hypomagnesemia
• severe asthma (refractory to bronchodilator x3)
• Gurkan F. Intravenous magnesium sulphate in the
  management of moderate to severe acute asthmatic
  children nonresponding to conventional therapy.
  Eur J Emerg Med. 19996201205
• Ciarallo L. Intravenous magnesium therapy for
  moderate to severe pediatric asthma results of a
  randomized, placebo-controlled trial. J Pediatr.
  1996129809814

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pharmacology - glucose

• infants
• high glucose requirements
• low glycogen stores
• prone to hypoglycemia during stress
• monitor glucose frequently
• 0.5 to 1.0 g/kg (10 or 25)
• or change to D5 or D10 containing solutions
  post-resuscitation

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pharmacology- sodium bicarb

• 1 Meq/kg
• 1 ml/kg 8.4 solution
• 2 ml/kg 4.2 solution for infants (decr. osm
  load)
• 1st ventilation, oxygenation, perfusion
• NB. again, most arrest respiratory therefore
  NaHCO3 could exacerbate
• indications
• hyperK, hyperMg, TCA, Na blking agents
• ?metabolic acidosis ?prolonged arrest

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pharmacology - naloxone

• neonatal resuscitation
• in mother whom received narcotics during delivery
• dose 0.1 mg/kg IM/IV/SC/ET

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post-resuscitation care

• continued support of ABCs
• intensive monitoring
• including frequent glucose, temperature
• preserve brain function
• avoid secondary organ injury
• seek and correct the cause of illness
• tertiary-care setting

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airway/breathing

• RR
• Infants 20-30
• Children 12-20
• TV
• 7-10 cc/kg
• peak pressures
• 20-25 cmH2O
• PEEP 2-5 cm H2O
• adjust to blood gases - PCO2 35

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circulation

• ongoing fluid resuscitation
• inotropes/vasopressors/vasodilators
• initially, may be unclear intensive monitoring
  environment
• shock
• hypovolemic
• cardiogenic
• septic in children response may be decreased
  myocardial function in sepsis (mixed picture)

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termination of resuscitation

• in general, 30 minutes
• absence of hypothermia, toxic drug overdose
• NB. ?family present during resuscitation?