P1252109398swYin

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Rationale for the Current Paediatric
Resuscitation Guidelines Bob Bingham RC (UK)
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Evidence?Janssens L, Altman S, Rogers PA.Vet
Rec105(12)273-6.

• Respiratory and cardiac arrest under general
  anaesthesia treatment by acupuncture of the
  nasal philtrum.
• In seven cases of anaesthetic apnoea with
  concurrent cardiac arrest and absence of vital
  signs, the revival rate was 43 per cent. Those
  which recovered required four to 10 minutes of
  acupuncture stimulation

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Plan

• Evidence evaluation
• BLS issues
• AEDs
• ALS issues
• Aspects of airway management
• Conclusions

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What we know for sure

• Children usually suffer from secondary cardiac
  arrest
• In c.90 of cases bradycardia precedes
  asystole/PEA
• Survival from respiratory arrest is good (c.70
  normal at 1 year)
• Bystander CPR is associated with improved
  survival
• Rescuers often do nothing for fear of causing
  harm - because theyre scared that children are
  different

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The Big Idea
A universal guideline for all
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For every complex problem there is an answer
that is simple, neat and wrong.

• H L Menken

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Effectiveness of ventilationcompression ratios
15 and 215 in simulated single rescuer
paediatric resuscitation E. Dorph, L. Wik and P.
A. Steen. Resuscitation 200254259
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Optimum CompressionVentilation ratio

• More compressions, better CPP
• More ventilation better oxygenation
• Optimum Balance?

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Optimum CompressionVentilation ratioBabbs CF,
Kern KB. Resuscitation 200254147-57
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Optimal CPR in ChildrenBabbs CF, Nadkarni V.
Resuscitation 200461173
Compression to ventilation ratios in CPR should
be smaller for children than for adults and
gradually increase as a function of body weight.
Optimal CPR in children requires relatively more
ventilation than optimal CPR in adults.
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So much for the Big Idea
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Piglet Model of Asphyxial Cardiac ArrestBerg et
al 1999. Crit Care Med271893-99
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Doing anything is better than doing nothing

• Ideally children should have a lower
  compression/ventilation ratio than adults
• Its no use having an ideal if no-one does
  anything

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Solution

• Those with a duty to respond will do something.
  They should employ the optimum, evidence based,
  sequence
• Other responders should be encouraged to do
  something by making only minimal necessary
  modifications to the adult protocol

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BLS simplifications

• Much of the wording harmonised with the adult
  text
• Age limits If you think the victim is a child,
  then he/she is!
• Chest compression landmarks avoiding abdominal
  compression
• AEDs

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AEDs
Problem is not giving too large a shock to a
child in VF Problem is giving ANY shock to child
not in VF
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Fear of Doing Harm

• LD50 of shock 470J/kgBabbs et al. Am Heart J
  198099734-738
• LD100 0Jkg (if in VF)

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AEDs In ChildrenRhythm Analysis

• Hazinski et al Circulation 1997Sensitivity
  100 Specificity 100
• Atkins et al Pediatrics 1998Sensitivity 88
  Specificity 100
• Ceccin et al Circulation 2002Sensitivity 100
  for VF Specificity 100

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Heartstart FR2 Automated External Defibrillator
(50J attenuator)
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Attenuated AEDsAtkins DL, Jorgenson DB.
Resuscitation 20056631-37

• Pads applied to 27 Patients
• 8 were in VF (age 4.5 months - 10 years)
• Shocks were advised and delivered to all
• No shock advised to any of the others
• All 8 defibrillated and admitted to hospital
• 5 discharged

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Are we going in the right direction?
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ALS

• ALS protocol
• VF
• Dose of adrenaline
• Airway management

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RhythmSamson R, Nadkarni V et al. NEJM
20063542328

• Prospective study of 1005 children with
• in-hospital cardiac arrest
• Non-shockable rhythm 73
• Survival 27
• Shockable rhythm 27
• Survival
• 35 (if VF initial rhythm)
• 11 (if VF occurred subsequently)

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VF Protocol

• Different aetiology - therefore consider
  precipitating causes
• Otherwise, no reason to differ from adult
  sequence
• 4J/kg only

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Dose of Adrenaline?

• 10mcg/kg?
• 100mcg/kg?
• For the 1st dose
• For the 2nd dose
• For subsequent doses

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High dose adrenaline

• Supported by animal studies and a single
  retrospective study in children
• No other studies have shown benefit

0/20 survivors after at least two SDE (historical
control group) 14/20 survivors with HDE after two
failed SDE 8/20 survived to discharge 3/20
neurologically intact at follow-up Goetting.
Annals Emerg Med 1991
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High dose adrenaline

• Perondi et al NEJM 20042501722-30
• Blinded PRCT
• 68 subjects randomised to HDE or SDE after 1x
  failed SDE
• 24 hr survival HDE 1/34 SDE 7/34
• Difference significant, but not maintained
  following adjustment for differences between the
  2 groups
• Significantly reduced survival from asphyxial
  arrest in HDE group

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Airway Management

• The Gold Standard
• LMA
• Cuffed tracheal tubes
• Other devices

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Effect of out-of-hospital paediatric endotracheal
intubation on survival and neurological outcome
a controlled clinical trial.JAMA. 2000 Feb
9283(6)783-90. Gausche M, Lewis RJ, Stratton
SJ, Haynes BE, Gunter CS, Goodrich SM, Poore PD,
McCollough MD, Henderson DP, Pratt FD, Seidel JS.

• Prospective randomised controlled trial
• 830 consecutive patients (lt12 years old)
• Randomised to BVM or ETI on odd or even dates
• Outcomes survival to hospital discharge and
  neurological status on discharge

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Outcome by Treatment Received

• ETI group 420 BVM group 410
• Survival
• ETI 25/185 (14)
• BVM 208/635 (33)
• Good neurological outcome
• ETI 15/185 (8)
• BVM 162/635 (26)
• BUT results were (correctly) analysed on an
  intention to treat basis

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Gausche et alJAMA. 283(6)783-90, 2000

• Outcomes

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Gausche et alJAMA. 283(6)783-90, 2000

• Complications

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LMAs?Lopez-Gil M, Brimacombe J et al. (1996)

• 8 anaesthesia residents
• 75 patients each (600 in all)
• The problem rate per patient for overall, major,
  and minor problems was 31.5, 12.8, and 18.7,
  respectively
• The problem rate decreased from 62 to 2 for
  overall problems and 23 to 2 for major problems
  over the 75 patients

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Cuffed Tracheal TubesKhine et al Anesthesiology
199786627-31

• 488 children (0-8yrs) undergoing general
  anaesthesia
• Initial size tube selected correctly more
  frequently with cuffed (age/43)
• Less leak
• Same complication rate

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Laryngeal Tube

• 0 Newborn lt5kg
• Infant 5-12Kg
• Child 12-25kg
• Small adult lt155cm
• Medium adult 155-180cm
• 5 Large adult gt180cm

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Laryngeal TubevsLMABortone L et al 2006. Paed
Anaesth16251-7
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ETCO2 Monitoring

• Tracheal tube placement detection reliable with
  perfusing rhythm and during transport
• What about during cardiac arrest?
• (Bhende et al Am J Emerg Med 199614349-50)
• Sensitivity 85
• Specificity 100

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Questions?
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Conclusions

• Paediatric resuscitation guidelines 2005
• Are evidence based - but its not level 1
  evidence!
• They are
• Simpler for professional rescuers
• Much simpler for lay rescuers