Pediatric

1
Pediatric
Resuscitation

• Ammar Al-Kashmiri
• R5 Emergency Medicine
• McGill University

2
Outline

• Outcome and Chain of Survival
• Recognition of a sick child
• BLS
• ALS

3
Challenges in Pediatric Resuscitation?

• Children are NOT just little adults!
• Different anatomy, different physiology and
  different pathology.
• Varying equipment shapes and sizes with varying
  ages.
• Challenging vascular access.

4
Outcome of cardiac arrest in children
Arrive in ER in cardiac arrest (N 80)
Admit PICU (N43) 54
Died in ER (N37) 46
Mod Deficit (N3)
PVS at 12 mos (N2)
Dead at 12 mos (N1)
Died in ICU (N37) 46
Schindler M, et al. Outcome of out-of-hospital
cardiac or respiratory arrest in children. N Engl
J Med 19963351473-1479
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Survival Rates in CPR

• In-Hospital 10
• Out of Hospital 10 - 34
• Isolated Respiratory Arrest 95

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Pediatric Chain of Survival
Prevention
ALS
CPR
EMS
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Adult Chain of Survival
CPR
ALS
EMS
Early Defibrillation
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To Simplifythe Message
8 years
Age
Early Defibrillation
With exceptions (sudden collapse, cardiac
history)
With exceptions (submersion, trauma, drug
overdose)
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Causes of Cardiac Arrest

• SIDS
• Trauma
• Submersion
• Poisoning
• Sepsis

• AW obstruction
• Severe Asthma
• Pneumonia
• Metabolic Disorders
• Arrhythmias

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Pediatric Cardiorespiratory Arrests
10
10
80
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Anticipating Cardiopulmonary Arrest
12
Shock
Resp. Failure
CARDIOPULMONARY ARREST
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Rapid Cardiopulmonary Assessment

• A- Airway
• B- Breathing
• C- Circulation
• Should take less than 30 seconds to complete

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Airway Assessment

• Able to maintain independently
• Requires adjuncts/assistance to maintain
  

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Evaluation of Respiratory Performance

• Respiratory Rate
• Respiratory Mechanics
• Retractions, Accessory Muscles use and Nasal
  Flaring
• Head Bobbing
• Grunting
• Stridor
• Wheezing

• Air Entry
• Chest Expansion
• Breath Sounds
• Color

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Cardiovascular Assessment
Heart rate BP Vol./strength of central
pulses Peripheral pulses Present/absent
Volume/strength Skin perfusion Cap.refill time
Temperature Color Mottling
CNS perfusion Responsiveness (AVPU)
Recognizes parents Muscle tone Pupil size
Posturing
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Basic Life Support
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Airway Management

• OBJECTIVE Maintain Patent Airway
• Open Airway
• Head-tilt/chin-lift method
• (big tongue, forward jaw displacement critical)
• Jaw thrust method with possible neck injury
• Suction
• Artificial Airways
• Oropharyngeal
• Nasopharyngeal

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Airway Management
Head Tilt-Chin Lift
Jaw Thrust
Avoid extreme hyperextension
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Breathing

• Look-Listen-Feel

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Breathing

• Objective Maintain Gas Exchange
• Rescue Breathing
• Mouth to mouth/nose-mouth
• Bag and Mask
• Self-inflating Bag-Mask
• w/o reservoir 30 -80 O2
• with reservoir 60-95 O2
• Do NOT use demand valve

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Breathing-How much and how fast?

• Adequate ventilation adequate volume x adequate
  rate
• Volume enough to cause chest rise
• over 1-1.5 sec (esophageal resistance may
  be overcome if faster)
• Rate 20/min
• synchronized w/ compressions at a ratio of
  15

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Breathing- Adjuncts
Oropharyngeal Airway
PROPER POSITION
SIZE
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Breathing- Adjuncts
Oropharyngeal Airway
IMPROPER POSITIONS
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Nasopharyngeal Airway
Breathing- Adjuncts
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Bag-Mask Ventilation
Breathing
Proper area for mask application
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Bag-Mask Ventilation
Breathing
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Bag-Mask Ventilation
Breathing
Sellick Maneuver
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Best Sign of Effective Ventilation

• Chest Rise

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Circulation

• Objective Maintain adequate blood flow to vital
  organs

How is this achieved by chest compressions?
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Circulation
Hemodynamics during CPR

• Heart Compression or Thoracic Pump Model?
• In children, direct cardiac compression is more
  likely to be important secondary to the childs
  compliant chest.
• ?compression should be directly over the heart

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Circulation

• In infants ? 1 finger breadth below intermammary
  line
• 2 fingers or thumbs encircling
• At least 100/minute
• 1/3 to 1/2 of chest

Brachial or femoral pulse is used to check for
pulse
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Circulation

• In older children ? the lower third of the
  sternum
• Maintain continuous head tilt with hand on
  forehead
• One hand
• 100/minute
• 1/3 to 1/2 of chest

Carotid pulse is used to check for pulse
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Circulation-Chest Compressions

• Absent pulse
• Heart rate lt 60 BPM (or lt 80 in infants-Rosen)
  with signs of poor perfusion

Indications for chest compression
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Best Sign of Effective Circulation

• Pulse with Each Compression

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Can CPR cause Retinal hemorrhages?

• Retinal hemorrhages are rarely found after chest
  compressions in patients with nontraumatic
  illnesses, and those retinal hemorrhages that are
  found appear to be different from the hemorrhages
  found in the shaken baby syndrome.

37
Advanced Life Support
38
Vascular Access
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Vascular Access Pearls

• Difficult compared to adults.
• Significant portion of kids respond to AW
  management alone!
• Time spent securing a vascular access at the
  expense of adequate AW management is a common
  mistake.
• Drugs can be given through ETT (LEAN).
• General order of attempts should be antecubital,
  hand, or foot and then intraosseous.

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Intraosseous Cannulation
Indication

• Vascular access required
• Peripheral site cannot be obtained
• In three attempts, or
• After 90 seconds

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Intraosseous Cannulation

• Devices
• 16 gauge hypodermic needle
• Spinal needle with stylet
• Bone marrow needle (preferred)

42
Intraosseous Cannulation
Site
Children 6 to 12 years of age A.
Medially to tibial tuberosity B. Above
medial malleolus C. Humeral head
Children 0 to 6 years of age A.
Medially to tibial tuberosity B. Above medial
malleolus
2-3 cm
1-3 cm
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Intraosseous Cannulation
Needle in place if

• Lack of resistance felt
• Needle stands without support
• Bone marrow aspirated
• Infusion flows freely

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Intraosseous Cannulation

• Contraindications
• Fractures
• Failed attempt on same bone

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Intraosseous Cannulation
Complications
Fluid escaping around the needle through the
puncture site.
Incomplete penetration of the bony cortex.
Fluid leaking through a nearby previous cortical
puncture site.
Penetration of the posterior cortex.
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What can be put thru an IO?

• Anything that can be put through an IV!

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Intubation
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Differences between the pediatric and the adult
airway
Larger in proportion to the oral cavity than in
the adult
Tongue
Epiglottis
Narrower, shorter, omega-shaped
Larynx
Higher in the neck (C3-C4) than in the adult
(C5-C6) not only positioned more anteriorly in
infants but positioned more cephalad
Cricoid
More conically shaped in infants narrowest
portion is at the cricoid ring, whereas in the
adult it is at the level of the vocal cords
Trachea
Deviated posteriorly and downward (becomes
anatomically similar to the adult between 8 and
10 years of age)
Head
Occiput relatively large compared with the
adults'Optimal intubating position is with
shoulder roll to prevent neck flexion in the
supine position
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(No Transcript)
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Effect Of Edema
Poiseuilles law
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Intubation
Indications

• Failure to oxygenate
• Failure to ventilate
• Failure to protect the airway
• Anticipation of worsening clinical course

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Tracheal Tube- size and depth?
Children gt 1 year ETT size
(Age16)/4 ETT depth (lip) ETT size x 3
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Tracheal Tube

• Children lt 8 years old
• Small tracheal diameter
• Narrow cricoid ring
• ?Uncuffed tubes

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Tracheal Tube

• The correct ID tube size is approximately the
  same size as the end of the patients pinky
• 1. True
• 2. False

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Tracheal Tube

• 2 studies show that this tenet does not hold
  true!

van den Berg AA, Mphanza T. Choice of tracheal
tube size for children finger size or
age-related formula? Anaesthesia.
199752701703 King BR et al. Endotracheal tube
selection in children a comparison of four
methods. Annals Emerg Med. 199322530534.
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Laryngoscope Blades
Better in younger children with a floppy
epiglottis
Straight
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Laryngoscope Blades
Curved
Better in older children who have a stiff
epiglottis
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Confirmation of ETT Placement

• Seeing tube go through cords
• Clinical Confirmation
• Water vapor seen inside tube
• O2 Saturation
• Chest rise
• Equal breath sounds
• No sounds over epigastrium
• CO2 Detection / Esophageal Detector Devices
• Chest X-ray

NO single technique is 100 reliable
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Acute Deterioration after Intubation
Displacement Obstruction Pneumothorax Equipment
failure
D.O.P.E
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Inadequate Improvement after Intubation?

• Inadequate Tidal Volume
• Excessive Leak Around The Tube
• Leak or Disconnection in Ventilator System
• Inadequate PEEP
• Inadequate O2 Flow from Gas Source
• Air Trapping and Impaired Cardiac Output

61
Laryngeal Mask
Higher success rate Does NOT protect from
aspiration Difficult to maintain during transport
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Cricothyrotomy

• Surgical contraindicated in children lt12
• Narrowing of trachea at cricoid ring makes
  procedure hazardous
• Use needle technique only

63
Drugs
64
Routes for Drugs in CPR

• Intravascular
• Intraosseous
• Endotracheal (LANE)
• LIDOCAINE
• ATROPINE
• NALOXONE
• EPINEPHRINE
• Note flush each medication with 3-5 ml of NS

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Oxygen

• Initiate ASAP
• Do not delay BLS to obtain oxygen
• Mouth-to-Mouth ventilation provides only 17 O2
• Indicated to all seriously ill or injured
  patients even if pCO2 is high
• Use highest possible FiO2 - No risk in short
  term100 O2
• Humidify if possible- avoids plugging airways,
  adjuncts

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Epinephrine

• Epinephrine Dosage
• IV or IO 0.01 mg/kg 110,000
• ET 0.1 mg/kg 11000

67
Epinephrine

• Epinephrine is effective in cardiac arrest
  because
• It has direct antiarrythmic effect on
  fibrillating myocardium.
• It enhances contractility through its ß1 receptor
  agonism effect.
• It increases SVR through its positive action on
  a1 receptors.

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Epinephrine

• Compared to regular dose Epinephrine, high-dose
  Epinephrine
• Improves outcome.
• Does not change outcome.
• May worsen outcome.

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Recent updates
A Comparison of High-Dose and Standard-Dose
Epinephrine in Children with Cardiac Arrest NEJM
35017 April 22, 2004

• Methods
• Randomized, double-blind trial.
• High-dose Epi as rescue therapy for in-hospital
  arrest after failure of an initial, standard
  dose of Epi.
• 68 children, Utstein-style.
• Primary outcome survival 24 hours after
  arrest.

• Results
• High-dose group tended to have lower 24-hour
  survival rate (OR for death, 7.9 97.5 CI
  0.9-72.5 P0.08).
• No difference in ROSC (OR 1.1 97.5 CI
  0.4-3.0).
• None in the high-dose group, as compared with 4
  in the standard-dose group, survived to hospital
  discharge.

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Calcium

• In infants, cardiac contractility depends on
  extracellular calcium influx since intracellular
  calcium is deficient.
• ?hypocalcemia can present with cardiogenic shock!
• There is no role for the empiric use of
  calcium.
• Indications for use
• Correct documented hypocalcemia.
• Antagonise hyperkalemia and hypermag.
• CCB toxicity.

Dose CaCl2 10 (100 mg/ml) 20 mg/Kg IV

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Sodium Bicarbonate

• NaHCO3 (1 mEq/ml)

1 mEq/kg IV
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Sodium Bicarbonate

• All of the following are true EXCEPT
• NaHCO3 inactivates catecholamines.
• NaHCO3 leads to increased CO2 production and
  worsening acidosis.
• No evidence shows an improvement in outcome when
  NaCO3 in administration during resuscitation from
  cardiac arrest.
• Attendance to rounds in negotiable by Ken.

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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

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Atropine

• All of the following are true regarding Atropine
  EXCEPT
• It increases SA and AV conduction through
  muscuranic antagonism.
• At low doses, it has central and peripheral
  parasympathomimetic actions which may lead to
  paradoxic vagotonic effects.
• In children, it is used to treat bradycardia
  empirically.
• It does not cause fixed and dilated pupils during
  cardiac arrest.

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What about Vasopressin?
76
Vasopressin

• 2000 AHA/ILCOR guidelines insufficient data to
  make any recommendations.
• Nadkarni et al. Beneficial effects of vasopressin
  in prolonged pediatric cardiac arrest a case
  series Resuscitation 2002 52149-156
• Retrospective case series of 4 patients only!

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Electricity and Arrhythmias
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Electricity

• 90 of pediatric cardiac arrest is
• Asystole, or
• Bradycardic PEA
• ?Defibrillation seldom needed

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Electricity

• 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
  paddles with A-P placement

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Defibrillation

• Energy Settings
• Initial 2 J/kg
• Repeat 4 J/kg

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Cardioversion

• Energy settings
• Initial 0.5 - 1.0 J/kg
• Repeat 2.0 J/kg
• Cardiovert only if signs of decreased perfusion

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Arrhythmias

• Tachycardias
• Sinus Bradycardia
• Pulseless Electrical Activity
• Asystole
• Ventricular Fibrillation
• Ventricular Tachycardia

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PEA

• Any organized rhythm without a detectable pulse
  (except VT)
• Treat like asystole with consideration of
  reversible causes

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Asystole

• Rate complete absence of any ventricular
  activity
• P waves in some cases P waves may be seen
• Pulse ABSENT

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Asystole/PEA
?
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Tachycardias

• Usually sinus tachycardia
• Do not cardiovert
• Look for treatable underlying cause

Narrow-complex tachycardia, rate lt 200
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Sinus Tachycardia
Causes

• Fever
• Shock
• Pain
• Hypovolemia
• Hypoxia
• Drugs
• Cardiac tamponade

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Tachycardias

• Usually supraventricular tachycardia
• Rhythm is REGULAR
• P waves may be difficult to see
• QRS is narrow
• Frequently associated with congenital conduction
  abnormalities
• If no conversion after two shocks, consider
  possibility rhythm is sinus tachycardia

Narrow-complex tachycardia, rate gt 230
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Supraventricular Tachycardia

• Stable ? Adenosine 0.05 - 0.1 mg/Kg IV
• Unstable ? Synchronized Cardioversion

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SVT
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Sinus Bradycardia

• Rate less than 60 BPM
• Rhythm regular
• P waves upright
• QRS following each P wave

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Sinus Bradycardia

• Most bradycardias respond to
• Oxygen
• Ventilation
• For bradycardia 2o to hypoxia/ischemia, preferred
  first drug is epinephrine

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Bradycardia

not an AHA recommendation!
k
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Update 2000 AHA/ILCOR guidelines
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VF

• Rate rapid, usually too disorganized to
  count
• Rhythm irregular, wave forms vary in size and
  shape
• NO P waves, QRSs, ST segments, or T waves
  discernable
• Pulse ABSENT

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VF
Pediatric VF suggests

• Electrolyte imbalances
• Drug toxicity
• Electrical injury

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Ventricular Fibrillation/VT
Amio. 5mg/kg bolus IV/IO or Lido. 1 mg/kg bolus
IV/IO/PT or Mg 25-50 mg/kg IV/IO for TDP or
hypomag.
?
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What is the rhythm?
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VT

• Rate close to normal to more than 400
• Rhyhm usually regular
• P waves often not recognizable
• QRS wide

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VT

• Pulseless treat as VF
• Pulse present
• Stable Amiodarone 5mg/kg
• Procainamide 15mg/kg
• Lidocaine 1 mg/kg
• Unstable Synchronized Cardioversion

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Questions