paediatric resuscitation november 2001. contents epidemiology eitiologies of arrest – focus on...
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epidemiologyeitiologies of arrest – focus on difference between adult and paediatricABC’s of peds resuscitation airway (RSI, LMA’s, etc)
neonatal resuscitation - briefpediatric cardiac rhythm disturbancescardioversion/defibrillation/pacingpost recovery care/termination of efforts
age definitions
newly born – first hours of life
neonate – first month
infant – neonate to 1 year
child – 1yr – 8yrs
adolescent - >8 yrs
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
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
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
eitiology
what about cardiac?witnessed Sudden collapsearrythmias
prior hx cardiac diseasecongenital prolonged QThypertrophic cardiomyopathydrug overdose
defib priority in these cases
airway
chin-lift/jaw thrustoropharyngealSize? central incisor to angle jaw
nasopharyngealcaution re: secretions, adenoids (difficult
insertion or external compression)
laryngeal masksintubation
LMA
Zideman D - Ann Emerg Med - 01-Apr-2001; 37(4 Suppl): S126-36 not studied in infant/child resuscitationcomplications more frequent in pedscorrect size 1 = smallest; 3-4 = adult female; 4-5 = adult male
may be dislodged during transport/CPRaspiration – 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
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
pediatric airway - differences
larger head and occiput neck flexion and airway obstruction when the child is supinerelatively larger tongue = less oral spacedecreased muscle tone = passive airway obstruction by the tongueepiglottis shorter, narrower, more horizontal, and softerlarynx anterior visualization of the cords difficulttrachea is shorter risk of right main stem intubationairway is narrower = increased airway resistancecricoid ring is the narrowest portion of the airway
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
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
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
sedation
thiopental – can induce bronchospasm (relatively contraindicated in asthmatics)
infants/neonates – more sensitive to fentanyl
fentanyl may increase ICP in children
TABLE 3 -- Suggested sedatives for selected clinical situations.
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
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
paralysis – rocuronium
infants and children0.6mg/kg paralysis in 60 seconds0.8mg/kg paralysis in 28 seconds
recovery 25% twitch<10 months old – 45 minutes5 years old – 27 minutes
reversal agents NB. be aware of myopathy with steriods
failed intubation
BMV with sellick maneuoverLMAlighted styletretrogradecricothyroidodomy 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
intubation
Miller blade or Mac in oldertube size 4 + age/4attempts should not exceed 30 seconds bradycardia (<60) hypoxia
depth of insertion (cm) tube ID (in mm) x 3. in children >2 years of age
depth of insertion (cm) = (age in years/2)+12.
direct visualization or breslow
confirm placement – end tidal CO2 etc
relative contraindications
evaluated as difficult intubation/difficult ventilationmajor facial or laryngeal traumaupper airway obstructiondistorted facial/airway anatomycaution 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
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 improve
survival over bag-mask ventilation in all EMS systems
endotracheal intubation appears to result in increased airway complications
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
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 acidosis on laboratory evaluation
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)
• heyond 10 years, SBP <90 mm Hg
NB. remember – hypotension is late finding in shock suggesting impending arrest
CPR
chest compressions with backboard two handed in infants
internal cardiac massage not recommendedchest wall compliance
vascular access
peripheralinterosseous 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)
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
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
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
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 meds4. evaluate color blue? supplemental O2
meconium
10-20% of all deliveriesintervention only with thick, particulate stained amniotic fluidsuction 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
rhythm disturbances
most often consequence not cause of arrestcorrect underlying causes
most asystolic or brady arrest
10-20% pulseless VT/VFProportion increases with age
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
bradyarrhythmias
treatmentepinephrine for hypotension/poor perfusion
primarily treatment of choice
atropine for vagal mediated, heart blkpacing for heart blk
refractory? epi or dopamine infusion
transcutaneous pacing
< 15kg paediatric electrodes
> 15kg adult
positioninganterior (+) – posterior (-)R infraclavicular (+) – L midaxillary 4th ICS
(+)
PEA
often represents a preterminal condition that immediately precedes asystole
frequently represents the final organized electrical state of a severely hypoxic, acidotic myocardium
PEA
hypovolemia
hypoxemia
hypothermia
hyperkalemia
tension pneumothorax
pericardial tamponade
toxins
pulmonary thromboembolus
tachycardia
narrow complexSVT – most common arrythmiasinus tachycardia
wide complexabberancy – uncommonVT/VF
SVT vs sinus tachycardia
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 - 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
ventricular arrhythmias – VT/VF
uncommon in children
eitiologycongenital heart dz, cardiomyopathy,
myocarditis reversable causes
metabolic (hyperK,hyperMg, hypoCa, hypoglyc)drug toxicityhypothermia
VT
stable – optionsamiodarone - 5 mg/kg over 20 to 60
minutesprocainamide - 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
unstablecardioversion – 2-4 J/kg
pulseless VT/VF
defibrillation – 2-4J/kg
ventilation, oxygenation, fluid resusc
epinephrine
shocks
shock resistant (ie. >4)?amiodarone 5mg/kg (max 15mg/kg/day)
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
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
pharmacology - epinephrine
epinephrine0.01mg/kg (1:10 000) q3-5 min during
arrest0.1mg/kg (1:1000) intratracheal
0.1-0.2mg/kg (1:1000) “high dose” not recommended
pharmacology - atropine
atropine0.02 mg/kgminimum 0.1 mg – < paradoxical bradymax 0.5mg in child x2 ; 1mg in adolescent
x2
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
pharmacology - calcium
calcium chloride0.2 mL/kg of 10% calcium chlorideslow infusion 20secs in arrest; 10 mins in
perfusing rhythm
indicationshypocalcemiahypermagnesemia?PEA ?asystole – not recommended
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. 1999;6:201–205
Ciarallo L. Intravenous magnesium therapy for moderate to severe pediatric asthma: results of a randomized, placebo-controlled trial. J Pediatr. 1996;129:809–814
pharmacology - glucose
infantshigh glucose requirements low glycogen storesprone to hypoglycemia during stress
monitor glucose frequently0.5 to 1.0 g/kg (10% or 25%)or change to D5 or D10 containing solutions post-resuscitation
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, perfusionNB. again, most arrest respiratory – therefore NaHCO3 could exacerbateindications hyperK, hyperMg, TCA, Na+ blking agents ?metabolic acidosis ?prolonged arrest
pharmacology - naloxone
neonatal resuscitation
in mother whom received narcotics during delivery
dose : 0.1 mg/kg IM/IV/SC/ET
post-resuscitation care
continued support of ABC’s
intensive monitoring including frequent glucose, temperature
preserve brain function
avoid secondary organ injury
seek and correct the cause of illness
tertiary-care setting
airway/breathing
RR Infants: 20-30 Children: 12-20
TV 7-10 cc/kg
peak pressures 20-25 cmH2O
PEEP 2-5 cm H2Oadjust to blood gases - PCO2 35
circulation
ongoing fluid resuscitationinotropes/vasopressors/vasodilatorsinitially, may be unclear – intensive monitoring environmentshock hypovolemic cardiogenic septic – in children response may be decreased
myocardial function in sepsis (mixed picture)