Jesse Rideout, MD, MPH, FACEPTufts Medical Center, BostonAssistant Professor of Emergency Medicine
Objectives• Identify challenges in pediatric resuscitation• Emphasize most pediatric cardiopulmonary arrests as the terminal point of respiratory failure or shock.• Review basic airway management and advanced airway management of respiratory distress• Review basic and advance management of shock• Outline updates to 2010 ILCOR for Pediatric and Neonatal resuscitation guidelines• Demonstrate principles with case presentations to emphasize key points
Challenges in PediatricResuscitation• It represents a rare event that is extremely stressful for clinicians and family members• Little opportunity to perfect resuscitation skills in real-life• Children are not simply little adults! – Differences in anatomy, physiology and pathology – Weight based dosing for medications, fluids and defibrillation – Varying sizing and shapes for critical equipment depending on patient age – Challenging vascular access
Pediatric CardiopulmonaryArrest (CPA)• much rarer than in adults• rarely a sudden event• rarely a primary cardiac cause• most often represents the terminal event of respiratory failure or shock.• Initial causes are diverse, depending on pediatric age group. They include: – Trauma – Sepsis – Hypovolemia (diarrhea) – SIDS – Submersion/Near Drowning
Outcome from CardiopulmonaryArrest (CPA) in Children is poor…. • Out-of-hospital CPA survival to hospital discharge – Overall survival: 6% – Most have poor neurological outcome • Infants: 4% (likely because of SIDS) • Children: 10% • Adolescents: 13% • Atkins DL, Everson-Stewart S, Sears GK, Daya M, Osmond MH, Warden CR, Berg RA. Epidemiology and outcomes from out-of-hospital cardiac arrest in children: the Resuscitation Outcomes Consortium Epistry- Cardiac Arrest. Circulation. 2009;119:1484 –1491. • In-hospital CPA survival to hospital discharge – Overall survival: 27% – Most have favorable neurological outcome • Tibballs J, Kinney S. A prospective study of outcome of in-patient paediatric cardiopulmonary arrest.
Causes of PediatricCardiopulmonary Arrest Respiratory Shock Cardiac
Anticipating Cardiopulmonary Arrest
Progression TowardPediatric Cardiopulmonary Arrest Many Causes (SIDS, Respiratory Infections, Sepsis, Trauma, Etc.) Respiratory Failure Shock CARDIOPULMONARY DEATH RECOVERY Good Neurological Poor Neurological Outcome Outcome
Evaluation of Respiratory Status Respiratory Rate Air Entry (Dependent on age) Chest Expansion Breath Sounds Respiratory Mechanics Color – Retractions, Accessory Muscles use and Nasal Flaring – Head Bobbing – Grunting – Stridor – Wheezing
Cardiovascular AssessmentHeart rate CNS perfusionBP Responsiveness Vol./strength of (AVPU)central pulses Recognizes parentsPeripheral pulses Muscle tone Present/absent Pupil size Volume/strength PosturingSkin perfusion Cap.refill time Temperature Color Mottling
Vital Sign VariationThe UPPER limits of respiratory rate and heart rate whileawake: Age Respiratory Heart Rate (years) Rate (beats/min) (breaths/min) Newborn 60 160 Infant 40 150 Toddler 34 140 School Age 30 120 Teenage 16 100 The LOWER limit of systolic blood pressure: Newborn: 60 mm Hg Infant: 70 mm Hg 1-10 years: 70 mm Hg + (2 x Age in years) >10 years: 90 mm Hg
Broselow Tape• A color coded, length based system• Drugs dosing and equipment are obtained based on child’s length• Extremely useful for rapid estimates during a pediatric resuscitation
Basic Airway Management Case 1:10 month-old boy is brought in by motheractively seizing, then becomes unresponsiveand stops breathing
Basic Airway Management• Basics of Pediatric Airway Management: – Position the head – Open the airway: jaw thrust – Clear the airway: Suction – Oxygenate – Consider Nasal or Oral Pharyngeal Airway – Bag-mask ventilation – Reassess
Basic Differences in the Pediatric AirwayComparison of adult and pediatric airways. (From Finucane BT: Principles ofAirway Management. Philadelphia, FA Davis, 1988.)
Differences between the pediatric and the adult airway Tongue Larger in proportion to the oral cavity than in the adult 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
Differences in Pediatric andAdult Airway: Effect Of Edema Poiseuille’s law 1mm of airway edema in the smaller infant airway will cause much greater resistance than in an adult
Basic Airway Management• Position the head – The proportionately larger occiput of an infant causes the head to flex on the neck which can obstruct the airway – Elevating under the shoulders with a towel places the airway in better alignment for infants.
Basic Airway Management• Open the Airway – The Tongue is the most common cause of airway obstruction • Chin lift (avoid in suspected trauma) • JAW THRUST – In a 2003 study by Bruppacher et al, the jaw- thrust was the most effective maneuver to overcome upper airway obstruction in children.
Airway Adjuncts• Oropharyngeal Airway (OP) – Helps prevent tongue from obstructing posterior pharynx – Potential use in unconscious patient – Cannot use in patients with intact gag reflex – SIZING: measure from corner of mouth to angle of jaw – PLACEMENT: direct method vs rotation method.
Airway Adjuncts• Nasopharyngeal Airway (NP) – Unconscious or depressed mental status – SIZING: Measure from the tip of the nares to the tragus of ear – CONTRAINDICATIONS: basilar skull fracture, midface fractures, bleeding disorders – Relative contraindication: children < 1 year old
Bag Mask Ventilation• Know the steps – Size the mask • Bridge of nose to cleft of chin – Select the bag • adult, pediatric, small child/infant, neonatal – Connect to oxygen – EC-Clamp – **Control your RATE and VOLUME
Bag Mask Ventilation• Most people over ventilate• Ventilation Rates: slower rates are best – avoid too fast and too hard – Neonates: 30 breaths/min – Infants: 10-20 breaths/min – Children: 8-10 breaths/min• The best predictor of effective ventilation is chest-rise.• Physiological tidal volume is 6-8 mL/kg. With additional amount added for dead space of bag-mask the volume needed is ~ 10 mL/Kg
Ventilation during CPR• AVOID BAGGING TOO FAST• Excessive ventilation is a very common problem and has serious repercussions – In animal studies, it has shown to decrease cerebral perfusion pressure, return of spontaneous circulation (ROSC) and survival – Excessive ventilation increases intrathoracic pressure, impedes venous return, reduces cardiac output and cerebral and coronary blood flow• **During CPR, ventilate 8-10 times per minute in infants and children
Basic Circulatory Management Case 2:16 month-old girl is taken to the ER withincreasing lethargy and dehydration with5 days of profuse diarrhea and poor P.O.
Case 2:• Assessment: – HR 170s, BP 60/palp, RR 40, Sat 93% Temp 37.6 C – Lethargic, diminished peripheral pulses, delayed capillary refill, poor skin turgor• Management: – Oxygen – Monitor (if available) – Finger stick glucose check: … 45 mg/dl (2.5 mmol/L) – Several attempts at intravenous access are unsuccessful ...
Intraosseous LineBest site of insertion: proximal tibiaLANDMARK: 1cm medial to tibial tuberosityVarious types of needles will work 16 gauge hypodermic needle spinal needle, bone marrow needle Hand-held electric operated (EZ-IO)
Intraosseous (IO)• Good literature to show that 100 IO is placed faster and with 100 67 greater success than 80 60 peripheral IV access in % success PIV (n=30) 40 IO (n=30) severely dehydrated children 20• Studies of animals 0 resuscitated from cardiac arrest have shown that 129 whether drugs are delivered 140 120 via peripheral intravenous, 100 68 central line (IVC) or tibial IO, sec 80 PIV (n=30) 60 plasma epinephrine levels 40 IO (n=30) and physiological changes 20 0 are equivalent time to placement Andropoulos, J Peds, 1990, Orlowski, Am J DIs Child, 1990 Bannerjee, Indian Peds, 1994
Intraosseus (IO) lines
What can be transfused through an IO line? ANSWER:Anything that can be transfused through an intravenous line
Pediatric Fluid Management• Fluid resuscitation – Isotonic crystalloid fluids: 20 mL/Kg over 10- 15min (repeat x1) • Normal Saline (or Lactated Ringers)• Trauma (hypovolemic shock) – Isotonic crystalloid fluids x 2 – Packed Red Blood Cells: 10 mL/Kg• Maintenance IV fluids: "4-2-1" Rule: – For 0-10kg: 4 mL/kg/hr – For 10-20kg: + 2 mL/kg/hr – For >20kg: + 1 mL/kg/hr
Case 2: 16 month boy in shock• While fluid resuscitating the child he decompensates further and becomes unresponsive and goes into cardiopulmonary arrest.• The monitor shows a narrow complex tachycardia 220 (Pulseless electrical activity)• …What are the next steps for optimal cardiopulmonary resuscitation ?• …What’s new from 2010 ILCOR update?
PEDIATRIC RESUSCITATION 2010 UPDATE: ILCOR• International Liaision Committee on Resuscitation (ILCOR) – October 2010 – 277 Resuscitation topics reviewed over 36 months – 356 experts from 29 countries• Forms the foundation for guidelines from: – Resuscitation Council of Asia – American Heart Association – Canadian Heart and Stroke Foundation – Australian Resuscitation Council – …others
2010 Guideline Changes toPediatric Basic Life Support• CPR sequence has changed from A-B-C (Airway-Breathing- Circulation) to C-A-B. – Start chest compressions before ventilations• Neonatal resuscitation continues to be A-B-C.
Why the change to C-A-B? • Most victims of cardiac arrest are adults with v-fib or v-tach who need compressions immediately to support circulation • Ventilation often delays initiation of chest compressions (by up to several minutes). • Recommendations needed to be simple and algorithms were becoming too complex • CPR is generally done poorly with excessive ventilations which can impede cardiac output • When chest compressions are interrupted, coronary perfusion pressure declines rapidly • Only 30% of pediatric CPA receive bystander CPR* • *Young KD, Seidel JS. Pediatric cardiopulmonary resuscitation: a collective review. Ann Emerg Med. 1999;33(2): 195–205
INFANT: Chest Compressions• 1 Rescuer • 2 Rescuers• Two-finger technique • Two-thumb-encircling• Mid-sternal, one finger- hands breadth below intra- • Lower 1/3rd of mid- mammary line. sternum “Push hard, push fast”: compress chest in infant 4cm – allow chest to recoil – at LEAST 100/min USE BRACHIAL OR FEMORAL ARTERY FOR PULSE CHECK Berg MD et al. Circulation 2010; 122:S862-S875
OLDER CHILD: Chest Compressions • In older children use the lower third of sternum • Use one hand • Maintain continuous head- tilt with hand on forehead • Feel for CAROTID artery for pulse-check“Push hard, push fast”: compress chest in infant 5cm – allow chest to recoil – at LEAST 100/min Berg MD et al. Circulation 2010; 122:S862-S875
Compression to Ventilation• Healthcare providers: – ALONE 30:2 – TWO OR MORE 15:2• Breaths: 8-10/min – Avoid excessive ventilation• Switch rescuers every 2 minutes to avoid fatigue when doing chest compressions
Circulation: DRUGS• Routes for drugs in CPR – Intravenous (IV) – Intraosseous (IO) – Endotracheal (ET) • L.E.A.N. – Lidocaine – Epinephrin – Atropine – Naloxone • Unpredictable absorption • Dosed higher than IV/IO (Epi is 10x higher)
Drugs• Epinephrine – IV/IO: 0.01 mg/kg (0.1mL/kg of 1:10,000) q3-5min – ET: 0.1 mg/kg (0.1mL/kg of 1:1,000) – IV drip: 0.1-1mcg/kg per minute IV/IO• Adenosine – 0.1mg/kg IV/IO rapid push (max 6mg); second dose 0.2mg/kg IV/IO• Amiodarone – 5mg/kg IV/IO bolus during cardiac arrest; repeat x2 for VF/Pulseless VT.• Atropine: – 0.02 mg/kg IV/IO (symptomatic bradycardia)
Electricity in Peds• Shockable rhythms: – Ventricular Fibrillation – Pulseless, Ventricular Tachycardia• Shock Energy for defibrillation – FIRST SHOCK: 2 Joules/kg – SECOND SHOCK: 4 Joules/kg
Case: 16 month old girl• Pulseless Electrical Activity (PEA) Arrest – High quality CPR: 15:2 (compressions to ventilations) – Epi 0.01 mg/kg IV/IO q3-5min – Address the REVERSIBLE CAUSES Hypovolemia Tension pneumothorax Hypoxia Tamponade, cardiac Hydrogen ion (acidosis) Toxins Hypoglycemia Thrombosis, pulmonary Hypo-/hyperkalemia Thrombosis, coronary
Hypoglycemia: Dextrose• <1 year: Dextrose 0.5-1 g/kg/dose. 5-10ml/kg of D10W• 1-12 years: Dextrose 0.5-1 g/kg/dose 2-4 ml/kg/dose of D25W• >12 years: Thiamine 100mg IV x 1 Dextrose 0.5-1 g/kg/dose 1-2 ml/kg/dose D50W
Advanced Airway Management Case 3:3 year old boy with cough, fevers and respiratorydistress.
Case 3:• Assessment: – HR=165 BP=60/30 RR=45 Sat 91% T. =39 C – Tachypnic with intercostal retractions, sitting forward, awake but depressed mental status, delayed capillary refill – CXR with bilateral infiltrates• Management: – Supplemental oxygen, intravenous fluid boluses and IV antibiotics initially help, but patient continues to deteriorate – Rapid sequence intubation (RSI) is considered
Pediatric Intubation Indications Failure to oxygenate Failure to ventilate Failure to protect the airway Anticipation of worsening clinical course
Rapid Sequence Intubation (RSI):7 Steps• Preparation: – equipment selection; positioning (towel under shoulders for infants; towel under head for small children); a second ET tube ½ size smaller; rescue devise such as LMA• Preoxygenation – 100% non-rebreather; avoid BVM if possible• Pretreatment – Lidocaine (head trauma) – Atropine• Paralysis with induction – Succynylcholine, rocuronium; Etomodate, Midazolam, Ketamine, Thiopental• Protection and positioning• Placement of ET tube in trachea• Postintubation management – Confirmation, CXR, secure tube
STEP 1: Preparation• Selecting ET tube size – Use charts based on weight or length – Use length-based resuscitation tape (Broselow) – Calculation of uncuffed ET tube size: • For age > 1 year: (age/4) + 4 • Premature infant: 2.5-3.0 mm • Newborn: 3.0-3.5 mm • Up to 6 months: 3.5 mm
Cuffed vs Uncuffed• What about cuffed vs uncuffed ET tubes? – Rational for uncuffed: consideration that the cuff causes pressure on the cricoid cartilage leading to pressure necrosis – There is evidence that this may not be as significant as once considered. – Conclusion in recommendations from American Heart Association: • Cuffed tubes may be preferred in certain situations including poor lung compliance, high airway resistance, or large glottic air leak – Use ½ size less for cuffed: (age in yrs/4) + 3.5
Blade Size• Miller 0 – premature infant or small newborn• Miller 1 – normal newborn to 12 kg (2 years)• Miller 2 – 13 to 24 kg (7 years)• Miller 3 – 25 kg + (8 years +)• **Macintosh may be used after 2 years of age• ** Miller 2 after age 2 (years)• **Too small a blade can get you into trouble
Miller Straight Blade Technique ET placement Miller (straight) blade allows for easier lifting of the floppy epiglottis
Pretreatment• Atropine: 0.02 mg/kg (min 0.1mg; max 0.5mg) – Rationale: used to blunt reflex bradycardia associated with RSI – Incidence: “evidence indicates that the incidence of reflex bradycardia in children undergoing RSI is much lower than previously thought” (Bean A, 2011) – Hypoxia is a greater predictor of bradycardia• Consider in infants < 1 yr and those children who receive a second dose of succinylcholine
Sedation / Induction Agents• US National Emergency Airway Registry (NEAR) most common sedatives used in RSI in children – Etomidate (42%) – Thiopental (22%) – Midazolam (18%) – Ketamine (7%) Sagarin MJ, et al: Pediatric Emerg Care 2002
Paralysis: Drugs Selection• More physician preference• Succinylcholine: 2-3mg/kg – Onset: faster – Duration: shorter – Adverse effects: more than Rocuronium• Rocuronium: 1mg/kg – Onset: Slower – Duration: longer – Adverse effects: less than Succinylcholine
Difficult Airway in Pediatrics• Need to anticipate this during initial assessment• Have contingency plan if you can’t intubate• Supraglottic devices (e.g. Laryngeal mask airway, LMA)
LMA• Sizes 1-5 – Use weight or length based system to determine required size – Size and mL needed to inflate the cuff on the side• Placement:
Pediatric Advance Life Support(PALS): 2010 Algorithms
2010 ILCOR UPDATE:Neonatal Resuscitation• Neonatal ventilation to compression ratio is 3:1 – Per cycle there are 90 compressions with 30 ventilations• Not necessary to do intrapartum suctioning (no improved outcomes)• Vigorous newborns do not require endotracheal suctioning for meconium stained amniotic fluid
2010 ILCOR Update:Post Resuscitation Care • Therapeutic Hypothermia: Children – Therapeutic hypothermia (32C to 34C) up to 72 hours may be considered in children with ROSC – May be beneficial for adolescents with out-of- hospital witnessed V-fib arrest
2010 Update: Post ResuscitationCare Recommendations• Therapeutic Hypothermia: Neonatal – Now several randomized controlled multicenter trials of induced hypothermia (33.5 C to 34.5 C) in newborns >36 weeks with moderate to severe hypoxic-ischemic encephalopathy showed improvement in neurodevelopmental disability at 18 month follow up for those cooled – Treatment should be commence within 6 hours following birth, continuation for 72 hours, and slow rewarming over at least 4 hours
Conclusions• Pediatric cardiopulmonary arrest is most often the terminal point of respiratory failure or shock and early intervention is critical• Effective basic and advance airway management in pediatrics can often avoid or revert cardiopulmonary arrest• Placing an Intraosseous line in a critically ill child without peripheral intravenous access is necessary• Know your key weight based drugs, equipment selections, and fluids in peds• Competence through deliberate practice with pediatric resuscitation and CPR should be stressed in emergency medicine training.