Resuscitation in Special Populations

Malik Al-Rawahi

Objectives

Resuscitation in Pediatric Population. Resuscitation in Pregnant Women.

Resuscitation in Pediatrics

Pediatric Cardiac Arrest: Secondary to respiratory failure or arrest.

Most Important Intervention: Oxygenation, ventilation.

Anatomy of the Pediatric Airway

Relatively larger head and tongue. More anterior larynx. Narrowest part of the airway: cricoid

cartilage. Long epiglottis (floppy, omega shaped). Easily compressed trachea.

Airway Evaluation

Mallampatti Classification. Cormack and Lehane Grades.

Difficult pediatric airway

Syndromes: Trisomy 21, Mucopolysaccharidoses, Pierre-Robin.

Trauma to head and neck. Possible epiglotitis. Radiation therapy. Masses in the neck.

Airway

Head-tilt/chin-lift.

Big tongue; Forward jaw displacement critical.

Avoid extreme hyperextension.

With possible neck injury, jaw thrust.

Breathing

Look-Listen-Feel.

Limit to volume causing chest rise.

Children usually underventilated.

Use BVM only if proficient.

Pedi BVM’s should not have pop-off valves.

Do not use demand valve on children.

Ventilate infants, children every 3 seconds.

Circulation

Infants: brachial.

Children: carotid.

Infant chest compressions. 2 fingers. 1 finger width below nipple line. 1/2 - 1 inches. At least 100/minute.

Circulation

Child chest compressions. One hand. Lower half of sternum. 1 - 1.5 inches. 100/minute.

Child CPR. Maintain continuous head tilt with hand on forehead. Perform chin lift with other hand while ventilating.

Best Sign of Effective Ventilation

Chest Rise.

Pulse with Each Compression.

Oxygen Therapy

Initiate ASAP.

Do not delay BLS to obtain oxygen.

Use highest possible FiO2.

• No risk in short term100% O2.

Humidify if possible.• Avoids plugging airways, adjuncts.

Endotracheal Intubation

Proper tube size. Newborn: 3.5 mm 4 months-1 year: 4.0 mm Child > 1 year: [(Age + 16 ) / 4]

Children < 8 years old.o Small tracheal diameter.o Narrow cricoid ring.o Uncufed tubes.

Infants, small children.o Narrow, soft epiglottis.o straight blade.

Endotracheal Intubation

Attempts not >30 seconds.

Bradycardia: oxygenate, ventilate.

Avoid hyperextension.

Use sniffing position.

Lift up; do not pry back.

Endotracheal Intubation

Confirm placement by: Seeing tube go through cords. Chest rise. Equal breath sounds. No sounds over epigastrium. CO2 in exhaled air.

Endotracheal Intubation

Mark tube at corner of mouth.

Avoid excessive head movement.

Frequently reassess breath sounds.

Ventilate to cause gentle chest rise.

Endotracheal Intubation

Drug administration. Do not delay while attempting IV access. Dilute with normal saline. Stop compressions. Inject through catheter passed beyond ETT. Follow 10 rapid ventilations.

Cricothyrotomy

Surgical contraindicated in children <12.

Narrowing of trachea at cricoid ring makes procedure hazardous.

Use needle technique only.

Vascular Access, Scalp Veins

No value in cardiac arrest.

Useful in infants < 1 year.

Hand, Arm, Foot Veins

22 gauge catheter for smaller children.

Restrain extremity before attempting.

Incise overlying skin with 19 gauge needle.

External Jugular

Life-threatening situations only.

If vein perforates, do not go to other side. Risk of paratracheal hematoma, airway

obstruction.

Prevention of Fluid Overload

Avoid using bags over 250cc.

Use mini-drip sets, Volutrols.

Fluid resuscitation: 20cc/kg boluses.

Intraosseous Cannulation

Placement of cannula into long bone intramedullary canal (marrow space).Indication: Vascular access required. Peripheral site cannot be obtained.

• In two attempts, or• After 90 seconds.

Contraindications: Fractures. Osteogenesis imperfecta. Osteoporosis. Failed attempt on same bone.

Intraosseous Cannulation

Site:Anterior tibia.1 - 3 cm below knee.Medial to tibial tuberosity.

Remember

You don’t need a line to give drugs during a code.

Epinephrine, atropine, lidocaine can go down tube.

Defibrillation

90% of pediatric cardiac arrest is: Asystole, or Bradycardic PEA.

Defibrillation seldom needed.

Pediatric VF suggests: Electrolyte imbalances. Drug toxicity. Electrical injury.

Defibrillation

Paddle diameter: Infants: 4.5 cm. Children: 8.0 cm.

Largest paddles that contact entire chest wall without touching.If pediatric paddles unavailable, use adult.Energy Settings: Initial: 2 J/kg. Repeat: 4 J/kg.

Cardioversion

Cardiovert only if signs of decreased perfusion.

Energy settings: Initial: 0.5 - 1.0 J/kg. Repeat: 2.0 J/kg.

Cardioversion

Narrow-complex tachycardia, rate < 200 Usually sinus tachycardia. Look for treatable underlying cause. Do not cardiovert.

Narrow-complex tachycardia, rate > 230 Usually supraventricular tachycardia. Frequently associated with congenital conduction

abnormalities.

Cardioversion

Narrow-complex tachycardia, rate > 230 If hemodynamically stable, transport. Adenosine may be considered.

Narrow-complex tachycardia, rate > 230 If hemodynamically unstable, cardiovert. If no conversion after two shocks, consider

possibility rhythm is sinus tachycardia.

Drug Therapy

Epinephrine:• Asystole, bradycardia PEA.• Stimulates electrical/mechanical activity.

Epinephrine Dosage:• IV or IO: 0.01 mg/kg 1:10,000.• ET: 0.1 mg/kg 1:1000.

Drug Therapy

Atropine: 0.02 mg/kg IV or IO.

Double ET dose. Minimum dose: 0.1 mg to avoid paradoxical

bradycardia. Maximum single dose:

Child: 0.5 mg. Adolescent: 1mg.

Drug Therapy

Most bradycardias respond to:o Oxygen.o Ventilation.

For bradycardia 2o to hypoxia/ischemia, preferred first drug is epinephrine.

Resuscitation in Pregnancy

There are two patients, mother & fetus.

The best hope of fetal survival is maternal survival.

Consider the physiologic changes.

Physiologic Changes

Compensate for increase metabolic demand. Prepare for blood loss at time of delivery. Alter presentation of injured women. Pregnant women is more vulnerable. Mask severity of injury.

Cardiovascular System

Increase in cardiac output ( 20-30%) Increase in heart rate ( 10-15 b/min) Decrease in systolic and diastolic pressure

(10-15) Increase in red blood cells and plasma (45%) Relative anemia. Increase to blood flow to uterus (up to 20%)

Respiratory System

Increase in RR due to upward pressure of uterus.

Increase in PCO2. Decrease in tidal volume.

GI System

Delayed GI emptying. Movement of abdominal organs. Uterus is the largest abdominal organ.

Shock

Body protect the mother: Uterine vasoconstriction 20-30%, decrease in

blood flow to uterus. Loss of 30-35% of blood volume before

developing hypotension, slow onset of signs and symptoms in mother.

But fetus is vulnerable to mild hypotension.

Interventions to Prevent ArrestTo treat the critically ill pregnant patient: Place her in left lateral position. Give 100% oxygen. IV access and give a fluid bolus. Consider reversible causes and identify any

preexisting medical conditions.

Always ABC. Focus on maternal resuscitation. Remember that signs of shock are late. Evaluate and treat hypovolumia aggressively.

Resuscitation of the Pregnant Woman inCardiac ArrestModifications of Basic Life Support

GA>20 weeks, uterus press against the IVC & aorta.

This can produce prearrest hypotension or shock and in the critically ill patient may precipitate arrest.

Limits the effect of chest compressions.

Modifications of Basic Life Support

Uterus may be shifted away from the IVC & aorta by placing in LUD or by pulling the uterus to the side.

This may be accomplished manually or by placement of a rolled blanket or other object under the right hip and lumbar area.

Airway

Hormonal changes promote insufficiency of the gastroesophageal sphincter.

Apply continuous cricoid pressure during positive pressure ventilation for unconscious pregnant woman.

Airway

Secure the airway early in resuscitation.

Use an ETT 0.5 to 1 mm smaller in internal diameter.

Breathing

Hypoxemia can develop rapidly because of decreased FRC & increased O2 demand.

Ventilation volumes may need to be reduced because of elevated diaphragm.

Circulation

Perform chest compressions higher, slightly above the center of the sternum.

Vasopressor agents, including epinephrine & vasopressin, will decrease blood flow to the uterus.

Defibrillation

Defibrillate using standard ACLS defibrillation doses.

There is no evidence that shocks from a direct current defibrillator have adverse effects on the heart of the fetus.

If fetal or uterine monitors in place, remove them before shocks.

Differential Diagnoses

Same reversible causes of cardiac arrest that occur in nonpregnant.

Providers should be familiar with pregnancy specific diseases & procedural complications.

Use of abdominal US should be considered in detecting possible causes of the cardiac arrest.

Iatrogenic

Overdose is possible in women with eclampsia.

Administration of calcium gluconate is treatment of choice.

It can be lifesaving.

Acute coronary syndromes

Pregnant women may experience ACS.

Fibrinolytics are relatively contraindicated, PCI is mangement of choice for STEMI.

Pre-eclampsia/eclampsia

Pre-eclampsia/eclampsia develops after the 20th week of gestation.

If untreated it may result in maternal and fetal morbidity & mortality.

Life-threatening PE & stroke

Successful use of fibrinolytics for a massive, life-threatening PE & ischemic stroke have been reported.

Trauma and drug overdose

Pregnant women are not exempt from the accidents & mental illnesses.

Domestic violence also increases during pregnancy.

Homicide & suicide are leading causes of mortality during pregnancy.

Aortic dissection

Pregnant women are at increased risk for spontaneous aortic dissection.

Emergency Cesarean Delivery forthe Pregnant Woman in Cardiac Arrest

The best survival rate for infants 24-25 weeks of gestation.

It should be done in < 5min from mother’s heart stops beating.

Emergency Cesarean Delivery forthe Pregnant Woman in Cardiac Arrest

Delivery, relieving both the venous obstruction and aortic compression.

It allows fast newborn resuscitation.

Remember that you will lose both mother & infant if you cannot restore blood flow to the mother’s heart.

Decision Making for Emergency Cesarean DeliveryConsider gestational age Fetal viability begins at approximately 24 to

25 weeks. Portable US, may aid in determination of

gestational age & positioning.

Decision Making for Emergency Cesarean DeliveryGestational age less than 20 weeks Unlikely compromise maternal cardiac output.

Gestational age approximately 20 to 23 weeks. Perform to enable successful resuscitation of the

mother, not the survival of the delivered infant.

Gestational age greater than 24 weeks. Perform to save the life of both the mother & infant.

Decision Making for Emergency Cesarean Delivery The following can increase the infant’s survival:

Short interval between the mother’s arrest & the infant’s delivery.No sustained prearrest hypoxia in the mother.Minimal or no signs of fetal distress before the mother’s cardiac arrest.Aggressive & effective resuscitative efforts for the mother.Delivery to be performed in a medical center with a NICU.

Thank You