Fran Lockie, a Paediatric Emergency and retrieval specialist, gives an update on paediatric resuscitation. This talk was given at the Bedside Critical Care Conference 2012 on Daydream Island.
pediatric assessment in emergency rooms , how to pass the PALS exam , part 1 search for the other 3 parts, for any comment send to sayedahmed 1900@ g mail .com
pediatric assessment in emergency rooms , how to pass the PALS exam , part 1 search for the other 3 parts, for any comment send to sayedahmed 1900@ g mail .com
Advanced cardiac life support or advanced cardiovascular life support (ACLS) refers to a set of clinical interventions for the urgent treatment of cardiac arrest, stroke and other life-threatening medical emergencies, as well as the knowledge and skills to deploy those interventions.
Perioperative considerations for OSA in ChildrenMd Rabiul Alam
Death after tonsillectomy related to haemorrhage may not be preventable. But death due to apnoea is preventable. More considered management is needed since: 10 deaths occurred at home, 2 in PACU and 3 in wards within 24 hrs of operation. These children could be saved by proper monitoring during operation night. Be aware of marked opioid sensitivity; reduce the dose by 50%. Codeine is to be avoided; Use NSAID, Dexamethasone. Develop an improved safety net for these high-risk children. High-risk patient : Nurse = 2 : 1
Advanced cardiac life support or advanced cardiovascular life support (ACLS) refers to a set of clinical interventions for the urgent treatment of cardiac arrest, stroke and other life-threatening medical emergencies, as well as the knowledge and skills to deploy those interventions.
Perioperative considerations for OSA in ChildrenMd Rabiul Alam
Death after tonsillectomy related to haemorrhage may not be preventable. But death due to apnoea is preventable. More considered management is needed since: 10 deaths occurred at home, 2 in PACU and 3 in wards within 24 hrs of operation. These children could be saved by proper monitoring during operation night. Be aware of marked opioid sensitivity; reduce the dose by 50%. Codeine is to be avoided; Use NSAID, Dexamethasone. Develop an improved safety net for these high-risk children. High-risk patient : Nurse = 2 : 1
Dr Andrew Stein, NHS England 7 Day Forum Member, Consultant in Renal and General Medicine, UHCW, Coventry. Andrew's slides from his presentation at the 7 Day services event in West Midlands, 11th June 2014.
CPR for the Foot - The approach in ScotlandDerek Jones
Presentation made at the Irish Association of Prosthetists and Orthotists meeting in Dublin featuring the work of the Scottish Foot Action Group in managing diabetic foot disease
Invited lecture by Dr Sujoy dasgupta in the Annual Conference of the "Academy of Clinical Embryologists" (ACE) held in October 2021 in "Hybrid mode" (Kolkata and Webinar)
Benjamin Leong - Dispatch assisted CPR in SingaporeRahul Goswami
Dr Benjamin Leong gives a comprehensive account of challenges and triumphs in the Singapore EMS - specifically the intervention of dispatcher CPR.
Find out more at singem.blogspot.sg
Osa in children by DR shashidhar tatavarthySHASHIDHAR T B
Management of OSA in children. evaluation tools, contraversies , surgeries and challenges in OSA made by Dr Shashidhar Tatavarthy. head of ENT at artemis hospitals
Similar to Update in Paediatric Advanced Life Support (20)
CORTICAL SPREADING DEPOLARISATION IN NEUROLOGICAL DISEASE – AN INTRODUCTION
By Toby Jeffcote
Cortical spreading depolarization (CSD) is a spreading loss of ion homeostasis, altered vascular response, change in synaptic architecture, and subsequent depression in electrical activity following an inciting neurological injury.
It was first described by Leão in 1944, a disturbance in neuronal electrophysiology has since been demonstrated in a number of animal studies, and recently a few human studies that examine the occurrence of this depolarizing phenomenon in the setting of a variety of pathological states, including migraines, cerebrovascular accidents, epilepsy, intracranial hemorrhages, and traumatic brain injuries. The onset of CSD has been demonstrated experimentally following a disruption in the neuronal environment leading to glutamate-induced toxicity. This initial event leads to pathological changes in the activity of ion channels that maintain membrane potential. Recovery mechanisms such as sodium-potassium pumps that aim to restore homeostasis fail, leading to osmolar shifts of fluid, swelling of the neuron, and ultimately a measurable depression in cortical activity that spreads in the order of millimeters per minute. Equally important is the resulting change in vascular response. In healthy tissue, increased electrical activity is coupled with release of vasodilatory factors such as nitric oxide and arachidonic acid metabolites that increase local blood flow to meet increased energy expenditure. In damaged tissue, not only is the restorative vascular response lacking but a vasoconstrictive response is promoted and the ischemia that follows adds to the severity of the initial injury. Tissue threatened by this ischemic response is then at elevated risk for CSD propagation and falls into a vicious cycle of electrical and hemodynamic disturbance. Efforts have been made to halt this spreading cortical depression using N-methyl-D-aspartate receptor antagonists and other ion channel blockers to minimize the damaging effects of CSD that can persist long after the triggering insult.
Celia Bradford takes us through the latest on the management of subdural haemorrhage (SDH). She covers acute SDH, chronic SDH and middle meningeal artery embolisation, a novel treatment for chronic SDH management in certain circumstances.
Andy Neill - More neuroanatomy pearls for neurocritical careSMACC Conference
Andy Neill shares some more neuroanatomy wisdom that's highly practical for anyone working with neuro emergencies. This time he covers brain herniation syndromes, hydrocephalus, extradural vs subdural haematomas, cervical spinal imaging, vertebral artery dissection and "things you read on CT reports but don't know what they mean"!
Andrew Udy talks about Brain Tissue Oxygen Monitoring:
It’s Not What You’ve Got It’s What You Do With It
The BONANZA Trial
Andrew Udy talks about the ongoing BONANZA Trial which is assessing whether an algorithm that incorporates both ICP and brain tissue oxygen (PbTO2) can improve outcomes after traumatic brain injury (TBI). Like with all monitoring, how the PbTO2 is interpreted and managed is critical and the devil is in the detail!
More on BONANZA here
More on BOOST3 here
R. Loch Macdonald, M.D., Ph.D.
Community Neurosciences Institute
Fresno, California, USA
Angiographic vasospasm and more accurately, delayed cerebral ischemia, continue to contribute to morbidity and mortality in patients with aneurysmal subarachnoid hemorrhage (SAH). It is known that angiographic vasospasm is common after SAH, occurring in two-thirds of patients. Cerebral infarctions that developed days after the SAH have been attributed to angiographic vasospasm, occuring in about a third of patients, although this has always been controversial. Angiographic vasospasm theoretically can only damage the brain by restricting blood flow but there is no easy, accurate, widely available method to measure cerebral blood flow and this is not the measurement we need. Blood flow depends on metabolic demand so what we need to know to determine if angiographic vasospasm is causing ischemia is oxygen extraction fraction in the brain tissue supplied the the spastic artery. Without this measurement, the attribution of ischemia to vasospasm is subjective. Since angiographic vasospasm is essentially the only detectable delayed phenomenon after SAH, we focus on it and apply tremendous resources to preventing or reversing the vasospasm. Undoubtedly angiographic vasospasm can cause cerebral infarctions, but it has to be severe and flow limiting. But SAH is a complex disease. There are many other causes for cerebral infarctions after SAH, the most common being due to the aneurysm repair procedure. And a given degree of vasospasm may cause infarction in a volume-depleted patient with poor collateral blood supply but not in a patient without these things. There also are hypodense brain lesions after SAH that are due to intracerebral hemorrhages. There can be hypodensities in the brain directly under usually thick SAH where the brain dies. This observation in particular supports a role for cortical spreading depolarizations/ischemia as a cause of infarction after SAH. Other macromolecular processes that are hypothesized to cause brain damage after SAH include microthromboembolism, changes in the microcirculation, delayed brain cell apoptosis and capillary transit time heterogeneity. Determining the importance of these things is hindered by the lack of an easy way to detect them in patients. It is also known that poor grade patients, who presumably have more early brain injury and ischemia than good grade patients, are more prone to delayed cerebral ischemia, suggesting increased sensitivity to secondary insults of the already injured brain. We also assume delayed neurological deterioration when attributed to vasospasm or delayed cerebral ischemia, is purely due to ischemia. While knowledge about what happens pathophysiologically after SAH is increasing, management of delayed cerebral ischemia still focuses on detecting angiographic vasospasm and then augmenting the blood pressure to improve cerebral blood flow or dilating the spastic arteries with balloons or drugs.
By Catherine Bell and Andrew Udy
Catherine Bell takes us through how to troubleshoot problems commonly encountered when looking after patients who have an external ventricular drain (EVD) in situ. Issues with using brain tissue oxygen monitors are also discussed. A highly practical session aimed at bedside clinicians.
There is no such thing as mild, moderate and severe TBI - by Andrew UdySMACC Conference
Part 2 of a debate over the classification of TBI. Andrew Udy then argues that this classification is fundamentally flawed. He discusses the issues with the Glasgow Coma Scale, and therefore the follow-on issues in TBI classification, including all the confounders to the GCS, the issues with timing of the score as well as GCS not taking baseline function or specifics subtypes of TBI into account. He makes teh argument that biomarkers may better categorise the diffuse entity we call TBI.
TBI Debate - Mild, moderate and severe categories workSMACC Conference
Andrew Chow, Intensivist with a neurosurgical background, argues that the current categorisation system for traumatic brain injury (TBI) works, and makes sense! He tackles us through the history of this system, and why it’s important to differentiate different types of TBI. The arguments in favour of this categorisation include the consistency and benefits of a universal language, the implications for triage and management, and the fact that this system has been endorsed by all major organisations
Dr Nick Little is an experienced Neurosurgeon who's looked after patients with traumatic brain injury for his whole career. Here he discusses the difficulties of prognostication following traumatic brain injury (TBI). He talks about the statistics of outcomes following mild, moderate and severe TBI and then goes on to tackle the harder topic of how we try to work out what an individual would want if they knew the spectrum of outcomes that they may face. The issues with the clinical examination findings we use to prognosticate are covered, as well as which imaging findings he finds most helpful. He also mentions the difficulties with current prognostic calculators.
Historically, when it came to brain injury, ketamine had a bad rap. Much of that dogma was dispelled in the last decade, and ketamine is now frequently used as an induction agent in acute brain injury, especially traumatic brain injury, due to it’s favorable effects on haemodynamics.
However a new application of ketamine is now being explored - whether ketamine may be able to reduce secondary brain injury.
Managing Complications of Chronic SCI by Bonne LeeSMACC Conference
20 million people around the world are living with a spinal cord injury (SCI). The medical issues they develop over the years differ to any other patient cohort.
These complications include autonomic dysreflexia, management of pressure areas, specific infections, nuanced peri-operative care and highly specific issues such as baclofen pump management and syringomyelia
Do look at the NeuroResus section on this and listen to Spinal Rehab Specialist Bonne Lee talk about this side of SCI care.
Keywords
SCI, spinal, spinal cord injury, autonomic dysreflexia, pressure areas, infection, peri-operative care, baclofen pump, syringomyelia, chronic SCI, spinal trauma, spinal rehab, incomplete SCI
Tania is a neurologist and epileptologist with expertise in continuous EEG (cEEG) and status epilepticus (SE). This talk covers what a seizure is, what status is, including focal and generalised status epilepticus.
So why do we do cEEGs for patients with suspected SE?
To confirm the diagnosis
To see if patient just post ictal or still seizing
To establish that the clinical and electric seizures have stopped
To see if burst suppression is achieved
To exclude other differential diagnoses
She makes a good argument for why cEEG is such an important tool in managing SE.
In the questions after the talk, the issue of availability of cEEG in the Australian setting was discussed. Limited montage EEGs are discussed including their pros and cons.
Stuart Browne is a Neuro Rehab specialist from Sydney. These slides accompany a talk he gave at the Brian Symposium in 2023. He discusses what "severe disability" really means.
Severe disability is more common than many realise - about 6% of the Australian population.
Stuart discusses how health is more than simply physical recovery and how it is a multidimensional construct. He covers how permanent disability doesn't necessarily equate to a poor quality of life. He also discusses the long timespan of recovery, which is often much longer than appreciated.
He specifically discusses "Locked-in Syndrome" and how the survivors have surprisingly positive self-reported health-related quality of life and well-being.
Stuart also covers how severely disabled people face various forms of discrimination.
Shree Basu is a Paediatirc Intensivist in Sydney. These slides from the Brain Symposium 2023 accompany the talk she gave. She discusses how Paediatric stroke presents, what neuroimaging is required and what interventions are available, including thrombolysis and the role of endovascular thrombectomy.
Hypertensing Spinal Cord Injury - gold standard or wacky?SMACC Conference
After spinal cord injury (SCI), there aren’t many interventions we have available that actually make a difference.
Augmenting blood pressure to increase spinal cord perfusion pressure is an attractive concept that may improve neurological outcomes following SCI. We know that hypotension can make SCI worse. Clinical studies looking at blood pressure augmentation are mostly old, retrospective and flawed in various ways.
Aiming for a MAP of > 85 for 5-7 days is recommended by guidelines but why this pressure and duration are good questions.
Hypertensive therapy is relatively safe and easy to implement but not without risk.
Tessa discusses the pros and cons, how this is managed practically and what the future may hold in this area.
Mark Weedon takes us through the increasingly utilised concept of an optimal cerebral perfusion pressure (CPPopt) for each unique patient. He discusses the background to CPPopt, including intrcranial pressure (ICP), the Monroe Kelly hypothesis, neurovascular coupling, and cerebral autoregulation in health and following brain injury. He shows how intracranial pressure is affected by intracranial compliance and how this affects ICP waveforms. Cerebral perfusion pressure in relation to the Brain Trauma Foundation guidelines is covered including management of elevated ICP (EICP). The currently recommended tiered approach to managing cerebral perfusion pressure and EICP is mentioned citing recent guidelines. He uses a clinical case of a TBI to illustrate how the CPPopt can be ascertained and used to guide therapy, including the easy to perform “MAP Challenge”. Mark also describes the Pressure Reactivity Index (PRx) and how it can be used as a target for therapy. Finally, he covers the exciting results of the preliminary COGiTATE pilot study.
Social Worker Victoria Whitfield and Bereavement councilor Louise Sayers discuss the power of words when health professionals are communicating topics around of death and serious injury with relatives and patients in critical care. They use role plays to bring theories to life.
Sepsis and Antimicrobial Stewardship - Two Sides of the Same CoinSMACC Conference
Appropriate use of antimicrobials is primarily a patient safety issue, and is the key aim of an effective antimicrobial stewardship program. We discuss the challenges in the management of a patient with sepsis, and how decision-making is usually done in the absence of effective diagnostics. Time dependent protocols and the knowledge that undertreatment of a patient with sepsis will lead to poor outcomes will lead to prescribing that may be driven by fear. Antimicrobial resistance is associated with over-use of antimicrobials but is usually not the immediate concern. Antimicrobial stewardship programs should work closely with sepsis teams to ensure that sepsis pathways are implemented across the whole hospital, and that key principles of judicious use are embedded within the clinical pathway.
Being able to prognosticate in the aftermath of a traumatic brain injury (TBI) is important as it assists with counselling patients and families. Moreover, it helps rationally allocate healthcare resources.
However, due to the heterogenous nature of TBI and variable pre brain injury patient factors and post brain injury course, this has proven to be a difficult task.
Large cohort studies have enabled improved accuracy in the prediction of 6 month mortality and unfavourable outcome.
Furthermore, many of the factors that contribute to long-term outcome have also emerged. However, it is not yet possible to use them in prediction algorithms or mathematical models.
There is emerging evidence that pre injury psychosocial and demographic factors may be of more relevance than injury severity. Moreover, that 'outcome' becomes increasingly subjective and complex as the post injury duration increases.
We end with three brief vignettes which highlight the fraught nature of long term outcome prediction.
1. Paediatric Resuscitation
Update
Bedside Critical Care,
Daydream Island
September 2012
Dr Francis Lockie,
Paediatric Emergency Department
Women’s and Children’s Hospital
MedSTAR Emergency Medical Retrieval
South Australia
2. Talk outline
• Scope of arrests in children
– Out-of hospital
– In hospital
• Resus update
• Improve survival
– Training
– Met teams
3. Out-of-Hospital Pediatric Cardiac Arrest:
An Epidemiologic Review and
Assessment of Current Knowledge
Ann Emerg Med. 2005 Dec;46(6):512-22
41 studies
5000 out of hospital paediatric arrests
Overall survival 12.1%,
Neurologically intact 4%
4. JAMA. 2006;295(1):50-57
Survival to hospital discharge 27% in kids (vs 18% in
adults)
Good neurological outcome in 17% (vs 13%) OR
First pulseless rhythm
oVF/pulseless VT: 14% vs 23%
oAsystole 40% vs 35%
oPEA 24% vs 32%
5. • Arrest in 111 of >100 000 admissions
• ROSC in 73%
• Survival to discharge 36%
• Hypotensive-bradycardia 66%
• Asystole 15%
• VF / pulseless VT 9%
• SVT
17. Where exactly does the
intraosseous (IO) fit?
Concerns re: complications
•Pain
•Success
•Extravasation
•Growth plate injury
•osteomyelitis
18. • 95 patients
• Mean age 5.5
• 95% success
• 10 seconds or less
• Pain score 2.3
Pediatr Emerg Care 2008
19. Hansen Pediatr Emerg Care 2011
• 291 patients
• 34% arrested
• 86% placed in
community hospitals
• 37% mortality
• NO
COMPLICATIONS
20.
21.
22. Pediatr Crit Care Med 2009 Vol. 10, No. 3
• Total hospital deaths decreased
from 4.38 to 2.87 / 1000 admissions
• 34 hospital deaths prevented each year of
MET operation
• Survival increased from 35% to 74%
• Annual calls went from 46 to 202 with MET
24. • The first 5 -10 minutes of aRescuers
Paediatric Life Support for Healthcare
paediatric collapse in a healthcare
setting
Basic Life Support occurs in the community by lay
• Includes CRM: equipment
people with no or little
teamwork, leadership
• Good uptake
– 8000 completed the e-learning
– 3600 completed short practical course
– 517 trainers
– 30 Super trainers
25. • Will be pre-requisite for DETECT junior in
NSW
• Adopted by Sunshine Coast, Qld
• Adopted by ACT Health
• Available to other States and Territories
for minimal cost
Resus4kids.com.au fenton.oleary@health.nsw.gov.au
26. Other issues covered
• Family presence during resus
• ECMO
• Complex congenital heart disease
• Trauma
– C-A-B approach
– Fluid restrictive resus
27. Other issues covered
• Family presence during resus
• ECMO
• Complex congenital heart disease
• Trauma
– C-A-B approach
– Fluid restrictive resus
• Don’t forget
– Parent education
– Public health measures
28. Summary
• Scope of paediatric arrests
• Whip through some recent changes
• How we can improve paediatric resus
outcomes for our patients
– Individual
– Hospitals
– State
Editor's Notes
There’s a big difference between out of hospital and in hospital arrests It’s interesting to see that there has been virtually no improvement in survival for pre-hospital arrest in the 50years since CPR has been developed. Incidence has gone down: that’s all down to public health! It’s a different story if you arrest in hospital! There’s been a huge improvement in survival if you arrest in hospital. Thanks to improvement sin resuscitation and training on many different levels. Look at some of the updates recommended by 2010 ILCOR collaborative and how they have been interpreted locally and internationally I’m going to talk about how we can improve the survival from paediatric cardiac arrest Let’s upskill ouselves but we have a responsibility to train others Can we improve things by training? Who should we train, and how What about Simulation What systems do we need to have in place to detect critical illness early How can we train junior doctors, medical students, nurses and ancillary staff to be expert resuscitators
41 studies >5000 12.1 and 4% intact Cf 5-13 % in adults reported in the 2010 JAMA article comparing no CPR - COCPR Submersion better22.7 /6 Better outcome with bystander CPR (OR 1.99 1.54-2.57)
BETTER SURVIVAL IN KIDS AND BETTER NEUROLOGICAL OUTCOME I WAS SURPRISED BY THE NUMBER OF KIDS PRESENTING WITH A SHOCKABLE RHYTHM SO WE REALLY HAVE TO KNOW OUR ALGORITHMS BACKWARDS NOT SURPRISINGLY MORE KIDS HAVE PEA ASYSTOLE NOT ALL BAD NEWS: IF KIDS HAVE PEA ? ASYSTOLE THEY ARE MORE LIKELY TO SURVIVE THAN THEIR ADULT COUNTERPARTS THIS SAYS KIDS MORE RESILIENT THAN ADULTS AFER PEA ? ASYSTOLE Context Cardiac arrests in adults are often due to ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT), which are associated with better outcomes than asystole or pulseless electrical activity (PEA). Cardiac arrests in children are typically asystole or PEA. Objective To test the hypothesis that children have relatively fewer in-hospital cardiac arrests associated with VF or pulseless VT compared with adults and, therefore, worse survival outcomes. Design, Setting, and Patients A prospective observational study from a multicenter registry (National Registry of Cardiopulmonary Resuscitation) of cardiac arrests in 253 US and Canadian hospitals between January 1, 2000, and March 30, 2004 . A total of 36 902 adults (≥18 years) and 880 children (<18 years) with pulseless cardiac arrests requiring chest compressions, defibrillation, or both were assessed. Cardiac arrests occurring in the delivery department, neonatal intensive care unit, and in the out-of-hospital setting were excluded. Main Outcome Measure Survival to hospital discharge. Results The rate of survival to hospital discharge following pulseless cardiac arrest was higher in children than adults (27% [236/ 880 ] vs 18% [6485/ 36 902 ]; adjusted odds ratio [OR], 2.29; 95% confidence interval [CI], 1.95-2.68). Of these survivors, 65% (154/236) of children and 73% (4737/6485) of adults had good neurological outcome. The prevalence of VF or pulseless VT as the first documented pulseless rhythm was 14% (120/880) in children and 23% (8361/36 902) in adults (OR, 0.54; 95% CI, 0.44-0.65; P <.001). The prevalence of asystole was 40% (350) in children and 35% (13 024) in adults (OR, 1.20; 95% CI, 1.10-1.40; P = .006), whereas the prevalence of PEA was 24% (213) in children and 32% (11 963) in adults (OR, 0.67; 95% CI, 0.57-0.78; P <.001). After adjustment for differences in preexisting conditions, interventions in place at time of arrest, witnessed and/or monitored status, time to defibrillation of VF or pulseless VT, intensive care unit location of arrest, and duration of cardiopulmonary resuscitation, only first documented pulseless arrest rhythm remained significantly associated with differential survival to discharge (24% [135/563] in children vs 11% [2719/24 987] in adults with asystole and PEA; adjusted OR, 2.73; 95% CI, 2.23-3.32). Conclusions In this multicenter registry of in-hospital cardiac arrest, the first documented pulseless arrest rhythm was typically asystole or PEA in both children and adults. Because of better survival after asystole and PEA, children had better outcomes than adults despite fewer cardiac arrests due to VF or pulseless VT.
HOW ABOUT IN AUSTRALIA? STUDY FROM RCH MELBOURNE REPORT 111 arrests in >100 000 ADMISSIONS SEEM TO BE DOING BETTER THAN THE REST OF THE WORLD!ACTUALLY Majority occurred in CICU Also reported on respiratory arrests from which survival was 97% BACKGROUND: Few prospective studies of the incidence and outcome of paediatric in-hospital cardiopulmonary arrest have been reported to enable quality assurance comparisons within and between institutions. METHODS: All cardiac and respiratory arrests and their management over a 41-month period in children not subject to palliative treatment or to a 'do not resuscitate' order were recorded and analysed using the Utstein template. RESULTS: Cardiac arrest occurred in a total of 111 of 104,780 admissions (1.06/1000) while respiratory arrest alone occurred in 36 (0.34/1000). Return of spontaneous circulation (ROSC) was achieved in 81 patients (73%) in cardiac arrest but only 40 (36%) were discharged from hospital and 38 (34%) survived for 1 year. The 1-year survival from respiratory arrest alone was 97%. Cardiac arrest was four times more common (89 versus 22) and approximately 90 times the incidence in the intensive care unit compared with wards but 1-year survival was similar (34% versus 36%). The initial heart rhythms were hypotensive-bradycardia in 73 (66%) with 38% survival; asystole in 17 (15%) with 12% survival; ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT) in 10 (9%) with 40% survival; pulseless electrical activity (PEA) in 10 (9%) with 30% survival and SVT in 1 with survival. Secondary ventricular fibrillation occurred in 15 children given adrenaline (epinephrine) for treatment of asystole, hypotensive-bradycardia or PEA of whom 11 had received adrenaline in an initial dose of > 15 mcg/kg and 4 had < 15 mcg/kg (P = 0.0013). Eleven of 15 patients (73%) in secondary VF never achieved ROSC. CONCLUSIONS: In-patient paediatric cardiac arrest has a mediocre outcome with a better outlook if the initial rhythm is hypotensive-bradycardia, VF or pulsatile VT. Doses of adrenaline greater than 15 mcg/kg given for non-shockable rhythms may cause secondary VF which has a worse outcome than primary VF.
NOW LET’S MOVE ON TO RESUS UPDATES ILCOR and CoSTR (Consensus on science with treatment recommendations) October 2010 277 resus topics reviewed over 36 months 356 experts from 29 countries Forms guidelines for many resus councils including ARC NZRC AHA: differs significantly from
I’t clear that there are different interpretations of the ILCOR CONSENCUS ON SCIENCE WITH TREATMENT RECOMMENDATIONS and It’s still an elephant, just looking it from different viewpoints.
DRSABC APPROACH COMMON TO ADULTS AND KIDS Two initial breaths rather than 5 breaths to achieve 2 effective breaths Recognises that kids more likely to have hypoxic aetiology for their arrest than adult counterparts. Central pulse for 10 seconds OR SIGNS OF LIFE EVEN THIS HAS BEEN CONTROVERSIAL IN AUSTRALIAN PAEDS COMMUNITY AND CHANGING COURSE CONTENT HAS BEEN A STRUGGLE A TIMES.
INTERPRETATION initially appearsVERY DIFFERENT IN THE US ACTUALLY SIMILAR RECOGNISES THAT ACTIONS OCURR SIMULTANEOUSLY IN THE TIME IT TAKES FOR SOMEONE TO GET OXYGEN , BVM, COMPRESSIONS COULD HAVE STARTED THE EUROPEANS HAVE STAYED WITH THE A-B-C approach and still advocate 5 rescue breaths Context Chest compression–only bystander cardiopulmonary resuscitation (CPR) may be as effective as conventionalCPRwith rescue breathing for out-of-hospital cardiac arrest. Objective To investigate the survival of patients with out-of-hospital cardiac arrest using compression-only CPR (COCPR) compared with conventional CPR. Design, Setting, and Patients A 5-year prospective observational cohort study of survival in patients at least 18 years old with out-of-hospital cardiac arrest between January 1, in , 2005, and December 31, 2009 Arizona . The relationship between layperson bystander CPR and survival to hospital discharge was evaluated using multivariable logistic regression. Main Outcome Measure Survival to hospital discharge. Results Among 5272 adults with out-of-hospital cardiac arrest of cardiac etiology not observed by responding emergency medical personnel, 779 were excluded because bystander CPR was provided by a health care professional or the arrest occurred in a medical facility. A total of 4415 met all inclusion criteria for analysis, including 2900 who received no bystander CPR, 666 who received conventional CPR, and 849 who received COCPR. Rates of survival to hospital discharge were 5.2% (95% confidence interval [CI], 4.4%-6.0%) for the no bystander CPR group, 7.8% (95% CI, 5.8%-9.8%) for conventional CPR, and 13.3% (95% CI, 11.0%-15.6%) for COCPR. The adjusted odds ratio (AOR) for survival for conventional CPR vs no CPR was 0.99 (95% CI, 0.69-1.43), for COCPR vs no CPR, 1.59 (95% CI, 1.18-2.13), and for COCPR vs conventional CPR, 1.60 (95% CI, 1.08-2.35). From 2005 to 2009, lay rescuer CPR increased from 28.2% (95% CI, 24.6%-31.8%) to 39.9% (95% CI, 36.8%-42.9%; P .001); the proportion of CPR that was COCPR increased from 19.6% (95% CI, 13.6%-25.7%) to 75.9% (95% CI, 71.7%-80.1%; P .001). Overall survival increased from 3.7% (95% CI, 2.2%-5.2%) to 9.8% (95% CI, 8.0%-11.6%; P .001). Conclusion Among patients with out-of-hospital cardiac arrest, layperson compression-only CPR was associated with increased survival compared with conventional CPR and no bystander CPR in this setting with public endorsement of chest compression–only CPR. JAMA. 2010;304(13):1447-1454 www
This could be the most important slide you see at this entire conference! Certainly having done my first APLS course about 10 years ago the following day I was faced with a blue, conscious child with an ineffective cough. Small piece of a plastic wrapper went flying across the room and normal play was resumed!
Concensus is emerging in the paediatric anaesthetic and ICU communities and it is common practice for cuffed ETT to be used in children over 1. In the era of safer high volume / low pressure ET cuffs mucosal ischaemia is rare if cuff inflating pressure is monitored and limited according to manufacturer’s instruction (usually less than 20 to 25 cm H2O). In theatre, cuffed endotracheal tubes are associated with a higher likelihood of correct selection of tube size, thus achieving a lower reintubation rate with no increased risk of perioperative complications. In intensive care settings the risk of complications in infants and in children is no greaterwith cuffed tubes than with noncuffed tubes. Cuffed endotracheal tubes may decrease the risk of aspiration. If cuffed endotracheal tubes are used, In certain circumstances (eg, poor lung compliance, high airway resistance, or a large glottic air leak) a cuffed endotracheal tube may be preferable to an uncuffed tube,provided that attention is paid to endotracheal tube size, position, and cuff inflation pressure
It’s amazing what can be achieved with good effective ventilation! bag-mask ventilation remains the recommended first line method for achieving airway control and ventilation in children, the LMA is an acceptable airway device for providers trained in its use.81,82 It is particularly helpful in airway obstruction caused by supraglottic airway abnormalities or if bag-mask ventilation is not possible. The LMA does not totally protect the airway from aspiration of secretions, blood or stomach contents, and therefore close observation is required. Use of the LMA is associated with a higher incidence of complications in small children compared with adults. The safety and value of using cricoid pressure during tracheal intubation is not clear. Therefore, the application of cricoid pressure should be modified or discontinued if it impedes ventilation or the speed or ease of intubation.
GOOD NEWS HERE< IT”S ALMOST IDENTICAL TO ADULT ALGORITHM Emphasis here on high quality CPR, minimising interruptions Vigorous attention to detail Early recognition of shockable rhythm, maintaining CPR until the defib is charged Early recognition of reversible causes
2005 ILCOR recommendation for IO use in cardiac arrest clear and widely accepted Increasing availability of drill powered insertion device (EZI IO) 2010 ILCOR reiterated message but added “ ..IO should be considered early in the care of critically ill children whenever venous access is not readily available ” 2010 multi-organisation consensus statement “ ….for whom vasc access cannot be readily or safely obtained IO access may prove a safe and viable alternative…. ”
2005 ILCOR recommendation for IO use in cardiac arrest clear and widely accepted Increasing availability of drill powered insertion device (EZI IO) 2010 ILCOR reiterated message but added “ ..IO should be considered early in the care of critically ill children whenever venous access is not readily available ” 2010 multi-organisation consensus statement “ ….for whom vasc access cannot be readily or safely obtained IO access may prove a safe and viable alternative…. ”
Objective: For decades, intraosseous (IO) access has been a standard of care for pediatric emergencies in the absence of conventional intravenous access. After the recent introduction of a battery-powered IO insertion device (EZ-IO; Vidacare Corporation, San Antonio, TX), it was recognized that a clinical study was needed to demonstrate device safety and effectiveness for pediatric patients. Methods: We measured the insertion success rate, patient pain levels during insertion and infusion, insertion time, types of fluid and drugs administered, device ease of use on a scale of 1 (easy) to 5 (difficult), and complications. Results: There were 95 eligible patients in the study; 56% were males. Mean patient age was 5.5 ± 6.1 years. Successful insertion and infusion was achieved in 94% of the patients. Insertion time was 10 seconds or less in 77% of the one-attempt successful cases reporting time to insertion. There were 4 minor complications (4%), but none significant. For patients with a Glasgow Coma Scale (GCS) score >8, mean insertion pain score was 2.3 ± 2.8, and mean infusion pain score was 3.2 ± 3.5. The device was rated easy to use 71% of the time (n = 49) and the mean score was 1.4. Conclusions: The results of this study support the use of the powered IO insertion device for fluid and drug delivery to children in emergency situations. The rare and minor complications suggest that the powered IO device is a safe and effective means of achieving vascular access in the resuscitation and stabilization of pediatric patients.
2005-2007, 291 patients across 90 hospitals (4/10 5 ED visits) Range of primary diagnoses, 34% were in cardiac arrest….others 86% of IOs placed in “ community hospital 37% mortality No complications related to IO line noted
Many AEDs can accurately detect VF in children of all ages.They can differentiate “ shockable ” from “ nonshockable ” rhythms with a high degree of sensitivity and Specificity It is recommended that systems and institutions that have AED programs and that care for children should use AEDs with a high specificity to recognize pediatric shockable rhythms and a pediatric attenuating system that can be used for infants and children up to approximately 25 kg (approximately 8 years of age)If an AED with an attenuator is not available, use an AED with standard electrodes (Class IIa, LOE C). In infants 1 year of age a manual defibrillator is preferred. If a manual defibrillator is not available, an AED with a dose attenuator may be used. An AED without a dose attenuator may be used if neither a manual defibrillator nor one with a dose attenuator is available (Class IIb, LOE C).
Let’s not forget the neonates! There is no more delay thinking which algorithm am I going to use! Strictly in the delivery room only They should now be resuscitated in air and oxygen only used if they are persistently bradycardic
PREVENTION BETTER THAN CURE and there are many early warning systems in place throughout the country Medical Emergency Team (MET – lead clinician Dr James Tibballs, Melbourne) – Children’s Early Warning Tool (CEWT) Kevin McCaffery – Paediatric Compass (lead clinician Dr Tony Lafferty, Canberra) – Paediatric Between The Flags (lead clinician Dr Jonny Taisz, Objective: To determine the effect of a medical emergency team (MET) on the incidence of unexpected cardiac arrest and death. Design: Comparison of retrospective data (pre-MET) before introduction of MET with prospective data after introduction of MET system (post-MET). Setting: Tertiary care pediatric hospital. Patients: A total of 104,780 admissions during a 41-month period pre-MET; 138,424 admissions during 48 months post-MET. Interventions: Introduction of a MET. Results: Total hospital deaths decreased from 4.38 to 2.87/ 1000 admissions (risk ratio 0.65, 95% confidence interval CI 0.57– 0.75, p < 0.0001). Ward unexpected death decreased from 13 (0.12/1000) to 6 (0.04/1000) (risk ratio 0.35, 95% CI 0.13– 0.92, p 0.03) but unexpected cardiac arrests did not change from 0.19/1000 to 0.17/1000 (risk ratio 0.91, 95% CI 0.50 –1.64, p 0.75). Thirty-four hospital deaths, including three unexpected deaths (1 out of 72 MET calls), were prevented each year of MET operation. Preventable cardiac arrest (children whose symptoms or signs fulfilled MET calling criteria) decreased from 17 (0.16/ 1000) to 10 (0.07/1000) (risk ratio 0.45, 95% CI 0.20–0.97, p 0.04) and in whom death decreased from 12 to 2 (0.11/1000 to 0.01/1000) (risk ratio 0.13, 95% CI 0.03– 0.56, p 0.001). Nonpreventable cardiac arrest (children whose symptoms or signs did not fulfill MET calling criteria) increased from 3 to 14 (0.03/1000 to 0.10/1000, p 0.03) but death did not increase. Survival from cardiac arrest increased from 7 of 20 patients to 17 of 23 (risk ratio 2.11, 95% CI 1.11– 4.02, p 0.01). Annual calls for urgent assistance were 202 in the post-MET era and 46 during the pre-MET era (ratio 4.4:1). Conclusions: Introduction of a MET was associated with reduction of total hospital death and reduction of preventable cardiac arrest and death with increased survival in wards of a pediatric hospital. MET calling criteria identified some but not all children at risk of unexpected cardiac arrest and death. (Pediatr Crit Care Med 2009; 10:306 –312) KEY WORDS: medical emergency team; cardiac arrest; death;
Enhancing Urgent Paediatric Care in NSW The Minister for Health, Jillian Skinner, today launched a range of clinical resources aimed at enhancing the recognition and management of sick infants and children in urgent or deteriorating situations. The resources were announced at the Child Health Networks Forum, “Caring for Children – Wherever they are.” The initiative is part of a state-wide education and support program. Mrs Skinner said the forum highlighted collaboration and mutual support across the spectrum of healthcare for children, with particular emphasis on rural facilities and acutely sick patients. “ Our clinicians in emergency departments and children’s wards are at the frontline of urgent action, and in effect are the ‘lifeguards’ of our hospitals,” Mrs Skinner said. “ These tools will further enhance the skills and knowledge for our clinical staff in handling patients who present as an emergency or with deteriorating conditions,” she said. “ Our priority is to equip our frontline staff with quality resources to allow them to continue providing patients with the safest possible care.” The new clinical resources are: The first chapter of the DETECT Junior manual: an online paediatric education program developed to enhance the recognition and management of clinically deteriorating infants and children. The NSW Rural Paediatric Emergency Clinical Guidelines : a companion document to help outline procedures to ensure the early management of children who present to Emergency Departments where Medical Officers are not immediately available. The Recognition of the Sick Baby or Child in the Emergency Department : guidelines to assist clinicians in early and rapid recognition of imminent risk in our young and very vulnerable patients. The resources have been developed through a collaboration of the Clinical Excellence Commission, the Rural Critical Care Taskforce and the Child Health Networks in NSW. All three resources help ensure that children who need it most receive safe and appropriate care wherever they are in NSW.
Family Presence During Resuscitation Family presence during CPR is increasingly common, and most parents would like to be given the opportunity to be present during resuscitation of their child.462–471 Studies show that family members who are present at a resuscitation would recommend it to others.462,463,465,471,472 Parents of chronically ill children are comfortable with medical equipment and emergency procedures, but even family members with no medical background who were at the side of a loved one to say goodbye during the final moments of life believe that their presence was beneficial to the patient,462–464,466,471–476 comforting for them,462–465,468–471,476 and helpful in their adjustment463–465,472,473,476,477 and grieving process.477 Standardized psychological examinations suggest that, compared with those not present, family members present during attempted resuscitations have less anxiety and depression and more constructive grieving behavior.477 Parents or family members often fail to ask, but healthcare providers should offer the opportunity in most situations.474,478,479 Whenever possible, provide family members with the option of being present during resuscitation of an infant or child (Class I, LOE B).474,478,479 Family presence during resuscitation, in general, is not disruptive, 464,472,475,476,480,481 and does not create stress among staff or negatively affect their performance.462,464,480,482 If the presence of family members creates undue staff stress or is considered detrimental to the resuscitation,483 then family members should be respectfully asked to leave (Class IIa, LOE C). Members of the resuscitation team must be sensitive to the presence of family members, and one person should be assigned to remain with the family to comfort, answer questions, and
Family Presence During Resuscitation Family presence during CPR is increasingly common, and most parents would like to be given the opportunity to be present during resuscitation of their child.462–471 Studies show that family members who are present at a resuscitation would recommend it to others.462,463,465,471,472 Parents of chronically ill children are comfortable with medical equipment and emergency procedures, but even family members with no medical background who were at the side of a loved one to say goodbye during the final moments of life believe that their presence was beneficial to the patient,462–464,466,471–476 comforting for them,462–465,468–471,476 and helpful in their adjustment463–465,472,473,476,477 and grieving process.477 Standardized psychological examinations suggest that, compared with those not present, family members present during attempted resuscitations have less anxiety and depression and more constructive grieving behavior.477 Parents or family members often fail to ask, but healthcare providers should offer the opportunity in most situations.474,478,479 Whenever possible, provide family members with the option of being present during resuscitation of an infant or child (Class I, LOE B).474,478,479 Family presence during resuscitation, in general, is not disruptive, 464,472,475,476,480,481 and does not create stress among staff or negatively affect their performance.462,464,480,482 If the presence of family members creates undue staff stress or is considered detrimental to the resuscitation,483 then family members should be respectfully asked to leave (Class IIa, LOE C). Members of the resuscitation team must be sensitive to the presence of family members, and one person should be assigned to remain with the family to comfort, answer questions, and