Resuscitation in infants and

children

The importance of respiratory support

Dr. Simon Erickson

Paediatric Intensive Care

Princess Margaret Hospital for Children

Paediatric cardiac

arrests

• uncommon (~20/100,000)

• more common in infants

• primary respiratory aetiology (80%)

• predominantly asystole/bradycardia/PEA (80%), VF/VT (4-14%)

• survival poor (9-20%) – Especially out of hospital

• functional outcome poor

• economic and social costs

Paediatric Cardiopulmonary Arrests

1° Respiratory

Shock

1° Cardiac

10% 10%

80%

Paediatric arrests

0

5

10

15

20

25

30

35

40

15 14 13 12 11 10 9 8 7 6 5 4 3 2 1

Age (years)

# A

rrests

Schindler M, et al. Outcome of out-of-hospital cardiac or

respiratory arrest in children. N Engl J Med

1996;335:1473-1479.

Arrive in ER in cardiac arrest

(N = 80)

Admit PICU (N=43) 54 %

Died in ER (N=37) 46%

Mod Deficit (N=3)

PVS at 12 mos (N=2)

Dead at 12 mos (N=1)

Died in ICU (N=37) 46%

Outcome-out of hospital arrests

Sirbaugh. A prospective, population-based study of the demographics, epidemiology, management

and outcome of out-of-hospital pediatric cardiopulmonary arrest. Ann Emerg Med 1999.

Arrive in ER in cardiac arrest

(n = 300)

ROSC n=33 (11%)

Discharge n=6 (2%)

Good outcome n=1 (<1%)

Outcome: in-hospital arrests

Inpatient arrests

n=880

ROSC n=459 (52%)

Survival to discharge

n=236 (27%)

Good outcome

n=136 (15%)

Nadkarni et al, First documented rhythm and clinical outcome from in-

hospital cardiac arrest among children and adults. JAMA 2006

Survival 24 hrs n=317 (36%)

Nadkarni et al, First documented rhythm and clinical outcome from in-

hospital cardiac arrest among children and adults. JAMA 2006

• Pre-arrest phase – monitoring/prevention/MET

– risk recognition

• No-flow phase – minimise

• Low-flow phase – optimise CPR

• Post-resuscitation phase – Immediate

• Optimise

• Hypothermia et al

• Prevent recurrence

– Rehabilitation

Pulse check

• Most studies show that neither laypersons nor healthcare professional can reliably detect pulse within 10 seconds – In children healthcare professionals detected a pulse

accurately in 80%

– 14-24% mistakenly detected pulse

– 21-36% missed pulse when present

• CPR should be commenced when – Unresponsive

– Not breathing

– No signs of life

CPR

• adverse consequences of compressions rare

• In any infant or child with HR < 60/min + poor

perfusion

• excellent standard compressions may provide up to

50% of normal cerebral blood flow

• “two thumb encircling-hands technique” is the

preferred technique in infants

• Compression: ventilation ratios

• Basic LS 30:2

• Advanced LS 15:2 (2 healthcare workers)

• Rates

– 100/minute for infants and children

• “Pause” for ventilations until ETT secured

Asystole/Bradycardia/PEA

Ventilate with O2 Initiate CPR

ADRENALINE 0.1mL/kg 1/10,000 IV/IO

OR 0.1mLkg 1/1,000 via ETT

ADRENALINE 0.1mL/kg 1/10,000 IV/IO 0.1mLkg 1/1,000 via ETT

Intubate IV/IO Access

Continue CPR 2-4 minutes

Consider IV fluids CPR 2-4 minutes

hypovolaemia

hypoxaemia

hypothermia

hypo/hyperkalaemia

toxins

tension

pneumothorax

tamponade

thromboembolism

Defibrillate 4J/kg

Defibrillate 4J/kg

Adrenaline 0.1 ml/kg 1/10000 IV/IO

Adrenaline 0.1 ml/kg 1/1000 ETT

Defibrillate 4J/kg

Amiodarone 5mg/kg

Witnessed arrest: 3 stacked shocks 2J/kg, 4J/kg, 4J/kg

VF/PULSELESS VT

hypothermia

hypoxia/acidosis

toxins

antiarrhythmics

congenital QT

electrolyte

disturbances

ischaemia

CPR 2 minutes

CPR 2 minutes

Ventilate O2

CPR 2 minutes

Adrenaline/Epinephrine

• Action primarily via

– : coronary perfusion pressure

– 1: contractility, automaticity, VF intensity

• Side effects:

– myocardial O2 consumption

– myocardial dysfunction

– post-arrest hyperadrenergic state

• 1991 large dose (200g/kg) A/W survival & neuro outcome in single non-blinded trial of 20 children

• Subsequent studies

– retrospective

– RCT 2003 (n=50)

0

10

20

30

40

50

60

70

ROSC 24-hour surv. Discharge

HDE SDE

Amiodarone in VF / Pulseless VT

• “Amiodarone for resuscitation after out-of-hospital cardiac arrest due to VF” Kudenchuk et al, NEJM, 1999

– Seattle 94-97, 500 adults randomised on presentation

– survival to admission (44% Vs 34%, OR 1.6 p=.02) but not survival

– treatment for hypotension (59% Vs 48%) or bradycardia (41% Vs 25%) with amiodarone

• “Amiodarone as compared with lidocaine for shock-resistant VF” Dorian et al, NEJM 2002

– RCT, n=347, out-of-hospital arrest

– amiodarone increased survival to admission (22% vs. 12%)

– survival to admission (27.7% vs. 15.3%) in those given drug in less than median time

• Limited experience in children

Defibrillation

• Biphasic defibrillators

– now widely available

– decrease impedance,

thus less peak current

required

– may be as effective at

less current with less

myocardial injury

– Mostly animal data

– Current

recommendations

• 150 joules for adults

• 2-4 J/kg for children

Defibrillation

• Stacked shocks vs.single shock – Long pauses in compressions assoc. with worse

outcomes

– Relatively high initial success rate

• Joules (2-4 J/kg) – Low success rate in termination of VF in children with

2 J/kg

– Threshold in animal studies-2.4-3.3 J/kg

• Paddle size – Size inversely proportional to impedance

• Position – No difference in impedance with paddle position

AED‟s in infants and children

• Many AED‟s can safely distinguish between shockable and non-shockable rhythms in infants

• Young myocardium may tolerate high energy doses

• Recommended order of preference

– Manual defibrillator

– AED with dose-attenuator

– AED without dose attenuator

Paediatric BLS sequence

SAFE approach

Are you OK?

Airway opening manouvres

Look, listen, feel

Up to five breaths

Check pulse

Start CPR

Call emergency services

1 minute

ie “phone fast”

“Rescue Breaths”

• No data to support any single number of initial

rescue breaths

• Two “initial effective breaths” should take priority

• ….”ideally…a pause between each breath…for the

rescuer to take a breath”

• BLS competency should include the skill of using

bag valve mask device

• Resus bags for full term newly born infants should

have a minimum volume of 450-500ml

Oxygen

• Good evidence supporting use of room air

vs. 100% O2 in newborn resuscitation

• Several animal studies suggesting

improved neurological outcome with room

air resus

• Insufficient evidence in children to support

any specific level of oxygen

Nasopharyngeal Airway

Contraindications:

Basilar skull

fracture

CSF leak

Coagulopathy

Length: Nostril to Tragus

Oral Airways

Airway Positioning

“Sniffing Position”

In the child older than 2 years

Towel is placed under the head

Laryngeal Mask Airway

• In adults easier to master than

intubation, in children training

& supervision needed to

master technique of insertion

• Range of sizes

• Airway not actually protected

from aspiration

• Difficult to maintain during

patient movement

• Relatively expensive

• Limited data in children not

recommended in children

during resuscitation

Bag-mask ventilation vs. intubation

• Intubation at scene by paramedics

– No difference in outcome in children after

cardiac or respiratory arrest

– Higher risk of mortality or neurological

disability in trauma patients

– Higher rate of intubation failure in children cf.

adults

Cuffed vs. uncuffed endotracheal tubes

• No studies looking at emergency intubation

• Randomised trials in the paediatric anaesthesia setting show that cuffed ETT

– Increase likelihood of correct sizing

– Don‟t increase the risk of airway complications

– May reduce risk of aspiration

– May reduce air leak in burns patients

Minute ventilation

• Ventilation during CPR increased ROSC,

survival, neuro outcome in animal studies

• Excessive ventilation is common in adult

resuscitation

• There are no data in children to identify

optimal minute ventilation during

resuscitation

• “Good adult evidence (and some evidence in

paeds) that ET CO2 level correlates with

effectiveness of ECM & prognosis

– ET CO2 and outcome of out-of-hospital cardiac arrest”

Levine et al, NEJM, 7/97: ET CO2 < 10mmHg at 10 mins =

100% predictive

– Strong correlation between ETCO2 and interventions that

increase cardiac output

– Association between low ETCO2 (<15mmHg) and failure

to ROSC after 15-20 mins resus

ETCO2

Post-resuscitation care

• Optimise organ perfusion

• Minimise organ stress

• Alteration of cytotoxic processes – Therapeutic hypothermia

– Neuroprotective agents

– Experimental agents

• Prediction/assessment of outcome – SSEP‟s

– EEG

• Rehabilitation

Hypothermia

• Animal studies have demonstrated that hypothermia is a potent neuroprotective therapy – Cerebral metabolism

– Apoptosis, calpain mediated proteolysis, mitochondrial injury

– Ion pumps and neuroexcitatory cascade

– Immune response and inflammation

– Free radical production

– Vascular permeability, oedema formation, vasc reactivity

– Cerebral thermo-pooling

Therapeutic hypothermia

• „Treatment of comatose survivors of out-of-hospital cardiac arrest with induced hypothermia‟ Bernard et al, NEJM 2002 – therapeutic hypothermia (33 deg. for 12 hours) improved

survival to rehab or home (49% vs. 26%), adjusted OR 5.25 (1.47, 18.76)

– hypothermia CI, SVR, glucose

• „Mild therapeutic hypothermia to improve the neurologic outcome after cardiac arrest‟ HACASG, NEJM 2002 – therapeutic hypothermia (32-34 for 24 hours) resulted in

improved neurologic outcome (CPC 1,2) 55% vs. 39% (OR 1.4)

– improved mortality at 6 months (41% vs. 55%) OR 0.74 (0.58, 0.95)

• Multinational pilot trial (HypCAP) underway in children

Human HIE Studies

• At least 4 neonatal studies underway, all cooling

for 72 hours

• Two completed neonatal studies positive

– Effect highly related to pre-randomisation amplitude

integrated EEG

– No effect if severely abnormal

– Large effect if moderately abnormal

– OR 0.42 (0.22-0.80), 58% relative reduction in severe

disability

– Reduced loss of grey matter

When should resuscitation be stopped?

• Discontinue if ROSC not achieved after 30

minutes of asystole unless „special‟

circumstances • refractory VF or VT

• toxin exposure

• electrolyte imbalance

• hypothermic injury

Family presence during resuscitation

• Most families want option to be present

during resuscitation

• Most families reported that being present

was beneficial

• Most studies suggest this is not harmful

but one reported short term emotional

difficulties

Role of simulation training

Experimental data

• Alpha-NME

– short-acting alpha-2 adrenergic agonist

– improves post-resuscitation ejection fraction

• Adrenergic receptor blockade

– both -blocker (prazosin) and -blocker (propranolol) and

combination given with epinephrine reduced post-resuscitation

myocardial dysfunction

• Biochemical markers

– post-arrest troponin levels are proportional to myocardial

dysfunction post-resuscitation both in animals and children

– non-specific enolase, S100-B

• Anti-oxidants/Room air resuscitation

• Modulating excitotoxicity

• Inducing hibernation

• Apoptosis

• Cold aortic flush

Conclusions

• Resuscitation medicine not an strong evidence-based area, especially in paediatrics

• Outcome of paediatric cardiac arrest remains poor

• Oxygenation of primary importance in resuscitation in infants and children – Both as a cause and a remedy

• Identification of risk factors and prevention a more effective strategy

• Dealing with patient, family and staff crucial following both successful and unsuccessful resuscitation