Michele Domico presents a talk on the pitfalls of common paediatric resuscitative manoeuvres in paediatric cardiac patients. Emergency and critical care physicians are all well accustomed to items such as oxygen, bolus adrenaline, intubation and cardioversion. However, as Michele explains, these ‘go to’ interventions may in fact be harmful for the paediatric cardiac patient presenting to the emergency department in extremis. Due to the physiology of certain complex congenital heart diseases, the usual resuscitation manoeuvres may in fact kill the patient instead of helping. Supplemental oxygen can worsen the pulmonary to systemic blood flow ratio in single ventricle patients and cause them to have rising lactate levels and cardiac arrest from low systemic cardiac output. Intubation and positive pressure ventilation may impede pulmonary blood flow in patients with a Glenn shunt and the patient can become more desaturated. With increasing PEEP and higher respiratory rates, the patients will continue to deteriorate and desaturate. Regular dosing of adrenaline boluses in patients with single ventricle physiology who are nearly arrest, can worsen their systemic output by increasing systemic vascular resistance and promoting pulmonary overcirculation. Cardioversion of a previously healthy paediatric patient might be tempting when you see what looks like a stable ventricular tachycardia. This wide complex rhythm has fooled many people into shocking it. You might in fact be dealing with something else and can make the patient infinitely worse by shocking. In her talk, Michele highlights the importance of understanding the physiology of your patients. This particularly applies to paediatric cardiac patients. In this population, the change from typical physiology means standard models of care are harmful. Tune in to hear what not to do! For more like this, head to our podcast page. #CodaPodcast

1. HOW USUAL RESUSCITATIVE MANEUVERS
CAN KILL PEDIATRIC CARDIAC PATIENTS
MICHELE DOMICO, MD
CHILDREN’S HOSPITAL OF ORANGE COUNTY, CALIFORNIA

2. N O F I N A N C I A L
D I S C L O S U R E S

3. O R A N G E C O U N T Y
C A L I F O R N I A

4. O R A N G E C O U N T Y, C A L I F O R N I A

7. W H E N O X Y G E N A N D
E P I N E P H R I N E M A K E T H E
S I T U AT I O N W O R S E

8. O X Y G E N D E C R E A S E S P V R
E P I N E P H R I N E I N C R E A S E S S V R

9. BABY PRESENTS WITH
MILD RESPIRATORY
DISTRESS AND POOR
PERFUSION
SATURATIONS 75%

10. MORE OXYGEN MORE BETTER?
WHAT WENT WRONG?

11. H Y P O P L A S T I C L E F T H E A R T S Y N D R O M E

12. H Y P O P L A S T I C L E F T H E A R T S Y N D R O M E
N O R W O O D P R O C E D U R E : S TA G E 1

13. B A L A N C I N G A C T B E T W E E N P U L M O N A RY
A N D S Y S T E M I C VA S C U L A R R E S I S TA N C E

14. OXYGEN
DECREASES
PULMONARY
VASCULAR
RESISTANCE
MORE BLOOD TO LUNGS

15. EPINEPHRINE INCREASES SVR
BLOOD FOLLOWS PATH OF
LEAST RESISTANCE
MORE BLOOD FLOW TO LUNGS

16. H L H S S TA G E 1
G O I N G S O U T H
GO AHEAD AND INTUBATE ME
DO NOT “OVER-DO” THE BLOOD
PRESSURE RESUSCITATION
LOW DOSE EPI (1/10th DOSE)
OR INODILATOR

18. 75% to 85%

19. W H E N I N T U B AT I O N A N D
P O S I T I V E P R E S S U R E
V E N T I L AT I O N
C A N A C T U A L LY D E C R E A S E
O X Y G E N AT I O N

20. D E C I S I O N T O I N T U B AT E
YOUR INTERVENTIONS MADE HIM WORSE

21. H Y P O P L A S T I C L E F T H E A R T S Y N D R O M E
S TA G E 2 : G L E N N P R O C E D U R E

22. PULMONARY BLOOD FLOW IS
DEPENDENT ON TWO THINGS:
INTRATHORACIC PRESSURE
BLOOD FLOW TO THE BRAIN
GLENN (STAGE 2)
PHYSIOLOGY

23. I F Y O U M U S T I N T U B AT E A S TA G E 2 ( G L E N N ) :
L O W E R P E E P A N D S L I G H T LY E L E VAT E D P C O 2
G I V E T H E M A L L T H E F I O 2 Y O U WA N T

24. W H E N D E F I B
PA D D L E S B E C O M E
Y O U R E N E M Y
P E R F E C T I S T H E E N E M Y O F G O O D

25. H E A LT H Y 8 Y E A R O L D G I R L
FAT I G U E , V O M I T I N G , “ H E A R T R A C I N G ”

26. A WA K E , TA L K I N G , P O O R D I S TA L P E R F U S I O N

27. DO NOT SHOCK

28. I N C I C U . M O R E H Y P O T E N S I V E . S T I L L A L E R T
LV EJECTION FRACTION 10%

29. C A R D I O V E R S I O N 1 J / K G
V F I B A R R E S T > 6 0 M I N U T E S O N T O E C M O

30. A N O N Y M O U S E L E C T R O P H Y S I O L O G I S T
YOU ARE NOT A TRUE INTENSIVIST
UNTIL YOU’VE TRIED TO SHOCK SINUS TACH

31. F E W H O U R S A F T E R E C M O A N D L E F T A T R I A L D E C O M P R E S S I O N

33. D E - N O V O “ V TA C H ” I N H E A LT H Y C H I L D R E N I S
M Y O C A R D I T I S U N T I L P R O V E N O T H E R W I S E
L E S S I N T E R V E N T I O N S T H E B E T T E R
U N L E S S A N E C M O C I R C U I T I S N E A R B Y

34. N O R W O O D S TA G E 1 S I N G L E V E N T R I C L E PAT I E N T S S H O U L D
H AV E S AT U R AT I O N S 7 5 - 8 5 % . D O N O T M A K E T H E M H I G H E R
I N C R E A S I N G S V R W I T H E P I C A N H A R M H L H S S TA G E 1 PAT I E N T S
S TA G E 2 ( G L E N N ) PAT I E N T S W I L L N O T O X Y G E N AT E W E L L
W I T H H Y P E R V E N T I L AT I O N O R H I G H P E E P
D O N ’ T S H O C K T H E H E A LT H Y C H I L D W I T H P U L S AT I L E “ V TA C H ”
S U M M A RY

35. M D O M I C O @ C H O C . O R G