PALS: New and Old

PALS:New and Old

David Chaulk

PEM Fellow

January, 22, 2004

Outline

• A&B then C– Illustrative Case– Back to Basics– Current Guidelines– Hot Topics

• Pre Hospital Care– Changes in the 2000 Guidelines

• When to stop

A&B….Case

• A 16 month boy presents to your ED and is noted to be seizing. From history it is not clear when the seizure started. Possibly an hour ago. You move him into the Resus room.

• He continues to seize. His vitals: HR 180, BP 105/65, RR 24 T 376 (T)

A&B…Case

• You give ativan 0.1mg/kg x2. Clinically he is not seizing but HR still high and GCS 3.

• You load with phenytoin 20 mg/kg

• No change.

• Decision: CT and intubate (failure to protect airway)

A&B…Case Questions

• What is the best method of estimating tube size?

• What is the evidence/guidelines for LMA use?

• How do we know that the tube is in place?

A&B… Anatomic Differences

• Relatively large tongue

• Funnel shaped trachea (subglottic narrowing)

• Larynx located anteriorly

• Short trachea (RMS intubation)

• Big head (large occiput causes flexion)

• Floppy epiglottis

A&B…Intubation

A&B…Intubation

• Tube Size• Methods

– (age/4) + 4– Broselow

• Hofer, et al., 2002– Formula

• overestimated tube size in >50%• Correct 41%

– Broselow• Tendency to underestimate• Correct 55%

A&B…Intubation

• Cuffed vs. Uncuffed– Recommendation is less than 8 years, uncuffed

A&B…Which Blade?

• No clearly defined guidelines– Younger child = floppier epiglottis– Use a straight blade and pick it up

– Older child = more like an adult– Curved blade and into vallecula

That’s some of the basics…what’s new and controversial?

A&B…The LMA

• Guideline ChangeThe LMA is a viable and effective alternative…for establishing the airway in children during resuscitation

Zideman, et al, Ann Emerg Med, Apr 2001

A&B…The LMA

• Clayton, et al., 2001• Airway management by OR nurses• Compared BMV and COPA (cuffed

oropharyngeal airway) in 40 anesthetized patients

• 32/40 (80%) successfully ventilated with BMV

• 38/40 (95%) success with COPA

A&B…The LMA

• Clayton, et al., 2001• Secondary Outcomes

– Mean expiratory volume better with LMA

– Leak was better with BMV • ?relevance if volumes are better with LMA

– Airway Trauma• BMV 0/40 (0%)• COPA 4/40 (10%)• Trauma described as blood tinged saliva upon removal of device

A&B…The LMA

• Important Notes– No LMA studies in PALS situations

– Unskilled (but trained) operators more successful with LMA then BMV

– LMAs may be easily dislodged

– Risk of aspiration lower than with BMV but still a risk• BMV 12%, LMA 3%

• Two studies, similar results Chibber et al., 1997 and Tobias et al., 1997

A&B…Esophageal?

• Previous Guideline (1992)

If the tube is in proper position, the chest should rise symmetrically during positive-pressure ventilation, and breath sounds should be easily auscultated over both lung fields and especially in the axillary areas. Breath sounds should be absent over the upper abdomen.

A&B…Esophageal?

• Proposed Change

A device should be used to confirm the position of the tracheal tube after each intubation in all settings (eg, outside-of-hospital setting, the emergency department, and in the intensive care unit).

Zideman, et al, Ann Emerg Med, Apr 2001

A&B…Esophageal?

• Colorimetric Devices

• Prospective study Bhende et al., 1992– 151 intubations , 137 children– 128/151 had perfusing rhythms

• Colour change PPV 100%

• No colour change NPV 100% (n=4)

A&B…Esophageal?

• 23/151 children were in cardiac arrest– No colour change NPV 84% 11/13

• Bhende et al., 1995– 40 children in cardiac arrest that were intubated– Colour change PPV 100%– No colour change NPV 60% (tube was tracheal

6/15 with no colour change)

A&B…Esophageal?

• Bhende et al., 2002– 39 intubations in 38 patients– Evaluated a newer device (Capno-Flo)

• 100% sensitive and specific (no false +/-)• Not useful for continuous monitoring

• Puntervoll et al., 2002– Intubated 14 patients tracheal and esophageal– Colorimetric accurate 100%– 5 patients instilled CO2 into esophagus…colorimeter

showed CO2 ?!

A&B…Esophageal?

• Colorimetric Device – Very accurate if colour change present– Questionable if no colour change– Questionable in cardiac arrest– Recommend 6 ventilations prior to decision-

making

A&B…Esophageal?

• Esophageal Detector Device (Briefly)– A syringe, easily w/d tracheal, not esophageal

• Morton (’89), 5-10 y and Wee (’91) 1-10 y– NPV and PPV 100% (Morton n=20, Wee n=100)

• Haynes and Morton (1991) 2w-9m, n=20– 25% failure rate, 3 false (+), 2 false (-)

– PPV 73%, NPV 78%

• Insufficient data to recommend EDD

A&B…Esophageal?This little Piggy went to market…

• 30 blinded volunteers assessing a 32 kg intubated Pig– EDD and CO2 NPV and PPV 100%– Clinical missed 3 esophageal tubes

• Secondary Outomes– EDD 13.8 s– CO2 31.5 s– Clinical 39 s

A&B…Esophageal?The Bottom Line

• Colorimetric changes are specific after 6 ventilations

• A positive colour change indicates correct placement of the tube

A&B…Esophageal?The Bottom Line

• No colour change is not helpful

• Not a reliable test in cardiac arrest

• In these cases, must rely on clinical evaluation and direct laryngoscopy that the tube is in position

Circulation & Cardiac Output

C…Case

• The mother of an 11 yo boy runs into the hospital with her limp child (he has a complicated PMHx).

• The nurse moves them to the Resus room and calls you stat.

• On history, he has had a brain tumour and has had a stroke in the recent past. He suddenly collapsed.

C…Case

• On examination he is making no respiratory effort, you do not detect a pulse and there is asystole on the monitor. His pupils are fixed and dilated.

C…Questions

• What is the best way to check cardiac activity in a potentially pulseless child?

• Is there a difference in location in terms of cardiac compressions?

• What is the most efficient method for attaining vascular access?

C…Questions

• Epinephrine. Standard or High Dose?

• What other drugs should be used?– Bicarb?– Vasopressin?

• Not related to this case but…What are the new guidelines for amiodarone?

C…Cardiac Activity

• New BLS guidelines (2000) state that the layperson should start CPR immediately if there are no signs of life because checking the pulse is inaccurate and time consuming

• What is the best method to assess cardiac output?

C…Cardiac Activity

• Ingawa et al., 2003

• Compared 5 techniques for assessing pulse– 28 OR nurses assessing 13 infants (with pulse)

Technique % identified (CI) Mean time (SD)

Auscultation 100 (51.8,100) 2.4 (1.2)

Apical 75 (28.9, 89.3) 3.5 (2.7)

Brachial 73.1 (52.2, 88.4) 4.0 (2.7)

Carotid 50 (30.6, 69.4) 9.9 (7.0)

Femoral 42.9 (24.5, 62.8) 9.1 (5.9)

C…Chest Compressions

• How should compressions be performed in infants?

• PALS guidelines– Two rescuers should use two thumb technique– Lone rescuer should use two finger technique

• Whitelaw et al., 2000– 209 participants compressing an infant model

C…Chest Compressions

• Whitelaw et al., 2000– 209 participants compressing an infant model

– 71% failed to give adequate compressions with either technique

– 19.1% were adequate with thumbs

– 18.1% were adequate with fingers (not statistically different)

• Finger group had more shallow compressions than thumb group (19.1% vs 7.2%)

C…Chest Compressions

• Finger Postion (PALS Recommendations)– Infants: 1 cm below intermammary line

– This is controversial

– Clements & McGowan, 1999 • Studied 30 adults and 30 children

• Measured the intermammary line distance to the xiphiod, mean distance 2.3 cm (range 1.0-3.5cm)

• Measured the distance the adults fingers would span using the recommended method

• Mean distance 4.4cm (range 4.0-5.5cm)

C…Chest Compressions

• Finger Postion (PALS Recommendations)– Children 1-8 years:heel of hand between

xiphoid and intermammary line

– Children > 8 same as adults

C…Prone Positioning

• Topic being looked at in the adult literature

• Mostly case reports

• 1 recent study

• Not mentioned in PALS

• Only 1 pediatric case report in the literature

C…Prone Positioning

• Theory:– Easier to learn and perform– Maintains airway – Minimal aspiration risk– Provides compressions and ventilatory assists without

the need to switch– Increased likelihood of bystander intervention with

elimination of need for MTM– Less likely to injury the victim if wrong diagnosis

» Stewart, 2002

C…Prone Positioning

• Mazer et al., 2003– Cross over study of 6 patients that failed 30

mins of standard CPR

– Given 15 (additional) mins of standard then 15 mins of prone CPR

– No patients had spontaneous return of circulation

C…Prone Positioning

Results

* Not significantly different

BP Standard CPR

Prone CPR Mean Change

SBP 48 72 23 + 14

MAP 32 46 14 + 11

DBP* 24 34 10 + 11

C…Prone Positioning

• 1 pediatric case report– 6 month old achondroplastic child in the OR– CPA– Successful Prone Position Resuscitation

C…Vascular Access

• Previous Guideline:– In children, 6 years of age and younger ,

intraosseous vascular access should be established if reliable venous access cannot be achieved within three attempts or 90 seconds, whichever comes first.

» JAMA, 1992

C…Vascular Access

• New Guideline– Intraosseous access should be established in any patient

when intravenous access cannot be rapidly achieved in the presence of cardiac arrest or decompensated shock.

» Atkins et al., 2001

– A practical approach is to pursue IO and peripheral or central access simulatneously

» PALS Provider Manual, 2002

C…Drugs

• Standard vs. High Dose Epinephrine– History

• Several animal studies in late 80’s suggested high dose epi (0.1mg/kg) was more effective than standard dose (0.01mg/kg)

• Small Pediatric study with similar results

• 1992 PALS Guidelines recommended first dose standard and second dose high

C…Drugs

• High vs. Standard dose Epinephrine– Since then multiple, large adult studies have

refuted this– Pediatric retrospective study of 51 patients and

58 CPA’s– 21 patients received HDE in 24 arrests– 30 patients received SDE in 34 arrests

C…DrugsResults

*significantly different

Outcome HDE SDE

ROSC 14 (58%) 24 (71%)

Time to ROSC* 19.0 (+ 12.1) 11.5 (+ 9.9)

Surv to 24h 7 (29%) 17 (50%)

Surv to 72h 6 (25%) 13 (38%)

Discharged 6 (26%) 7 (23%)

C…Drugs

• Current Epinephrine Guidelines– Standard dose epinephrine for initial and

subsequent

– The PALS provider may consider high dose epinephrine by intravascular route

» PALS Provider Manual

C…Drugs

• What is the role of Vasopressin?– No indication in the current guidelines

– A hot topic both in pediatric and adult critical care and resuscitation

– Little evidence (for or against) in pediatrics

C…Drugs

• Vasopressin– Voelckel compared Epi and AVP in piglet

pediatric models (2000 and 2002)– 2000, looked at asphyxia

• Epi not different than epi and AVP, superior to AVP alone

– 2003, looked prolonged VF• Epi and AVP superior to epi or AVP alone

– Outcome in both was LV blood flow

C…Drugs

• Mann et al., 2002– Retrospective analysis of 6 arrests in 4 patients– Given as “intervention of last resort”

• ROSC > 60 mins in 4 of 6 • 2/4 patients survived > 24 h• One surivived to discharge • One family withdrew care

• Vasopressin not recommended at this time (class indeterminate)

C…Drugs

• What about bicarb?– Very little pediatric literature, even less in CPA

– Recommendations extrapolated from adult, animal and DKA research

– Recommendations have changed in the current PALS

C…Drugs

• The Current Guidelines…– …the routine use of (bicarb) does not consistently

improve outcome of cardiac arrest.» Vukmir, 1995 (dogs) and Levy, 1998 (adults)

– Bicarb causes CO2 retention. Since most pediatric arrests are respiratory, bicarb may be detrimental

– May have a role in prolonged arrest

C…Drugs

• The Current Guidelines…– Indications for Sodium Bicarbonate

• Severe metabolic acidosis with effective ventilatory support

• Hyperkalemia

• Hypermagnesemia

• TCA overdose

• Na channel blocker poisoning» Pals Provider Manual

C…Drugs

• Amiodarone– Added to refractory VF/VT guidelines

– No evidence for use in Pediatrics as of 2000. Class indeterminate, LOE 7

– All evidence extrapolated from adults and animals

C…Drugs

C…Drugs

• Amiodarone– Dose is 5 mg/kg given rapidly via IV/IO

– Major side effect is profound hypotension in 10-20%

– Also may be considered in stable tachycardia after consultation with cardiologist

Pre Hospital CareA Brief Review of the Changes

Prehospital PALS Changes

• Phone first vs. Phone Fast– Younger than 8

• 1 minute of CPR then activate EMS

– Older than 8• Activate EMS then initiate CPR

– If two people, do both– If known etiology a health professional should

act accordingly– The benefit of phone first is faster defibrillation

Prehospital PALS Changes

• Out of Hospital…Intubation vs. BVM– Previous Guidelines

• Ventilation through an endotracheal tube is the most effective and safe ventilatory method….

– JAMA, 1992

Prehospital PALS Changes

• New Evidence– 830 patients under 12 y.o and estimated <40 kg

• BVM on odd days, n=410

• BVM followed by ETI on even days, n=420

– Outcome measures• Survival to hospital discharge

• Neurologic status at discharge

Prehospital PALS Changes

• Results– No significant difference in survival

• BVM 123/404 (30%)

• ETI 110/416 (26%)

– No significant difference in good neurologic outcome

• BVM 92/404 (23%)

• ETI 85/416 (20%)

Prehospital PALS Changes

• Conclusion– Addition of ETI to out of hospital pediatric

airway management does not improve survival or neurologic outcome

• Gausche, et al., JAMA, 2000

Prehospital PALS Changes

• Guideline Change– Anyone responsible for out-of-hospital life

support for infants and children should be trained to provide effective oxygenation and ventilation with the BVM technique as the primary method of ventilatory support, particularly if transport time is short

– Zideman, et al., JAMA, 2000

Prehospital PALS Changes

• AEDs– Guideline

• AEDs may be used for rhythm classification in children >8 years old but are not acceptable for children < 8 years old

• Attempts to defibrillate children < 8 years old with the energy doses currently available in AEDs are not recommended at this time

• It is acceptable to use 150-200J biphasic shocks in children in VF if they are 8 years old or older

When to Stop

• Failure to respond to two doses of epinephrine with ROSC

• In the absence of– VF/VT– Toxic drug exposure– Primary hypothermic insult

• Resuscitative efforts may be discontinued if there is no ROSC despite ALS interventions

• In general, this requires no more than 30 minutes

On that happy note…Thank you for your attention!

Thanks to Dr. David Johnson for his help in preparing this talk !