Pediatrics' CPR 2005

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Information about Pediatrics' CPR 2005

Published on July 16, 2009

Author: behdad16


Pediatrics' CPR : Pediatrics' CPR Directed By: Mohammad Langeroodi M.D. Pediatrician Behdad Bazargani M.D. Anesthesiologist Pediatric : Pediatric Mohammad Langaroodi M.D. Neonatologist-Pediatrician Hedayat Hospital - 2009 Resuscitation Slide 3: Outline Outcome and Chain of Survival Recognition of a sick child BLS ALS Challenges in Pediatric Resuscitation? : Challenges in Pediatric Resuscitation? Children are NOT just little adults! Different anatomy, different physiology and different pathology. Varying equipment shapes and sizes with varying ages. Challenging vascular access. Slide 5: 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 % Mod Deficit (N=3) PVS at 12 mos (N=2) Dead at 12 mos (N=1) Died in ICU (N=37) 46% Outcome of cardiac arrest in children Died in ER (N=37) 46% Survival Rates in CPR : Survival Rates in CPR In-Hospital 10 % Out of Hospital 10 - 34 % Isolated Respiratory Arrest 95% Pediatric Chain of Survival : Pediatric Chain of Survival Prevention ALS CPR EMS Adult Chain of Survival : Early Defibrillation Adult Chain of Survival CPR ALS EMS To Simplifythe Message… : To Simplifythe Message… Early Defibrillation 8 years Age With exceptions… (submersion, trauma, drug overdose) With exceptions… (sudden collapse, cardiac history) Causes of Cardiac Arrest : Causes of Cardiac Arrest SIDS Trauma Submersion Poisoning Sepsis AW obstruction Severe Asthma Pneumonia Metabolic Disorders Arrhythmias Pediatric Cardiorespiratory Arrests : Pediatric Cardiorespiratory Arrests 10% 10% 80% Slide 12: Anticipating Cardiopulmonary Arrest Slide 13: Shock Resp. Failure CARDIOPULMONARY ARREST Rapid Cardiopulmonary Assessment : Rapid Cardiopulmonary Assessment A- Airway B- Breathing C- Circulation Should take less than 30 seconds to complete Airway Assessment : Airway Assessment Able to maintain independently Requires adjuncts/assistance to maintain Evaluation of Respiratory Performance : Evaluation of Respiratory Performance Respiratory Rate Respiratory Mechanics Retractions, Accessory Muscles use and Nasal Flaring Head Bobbing Grunting Stridor Wheezing Air Entry Chest Expansion Breath Sounds Color Cardiovascular Assessment : Cardiovascular Assessment Heart rate BP Vol./strength of central pulses Peripheral pulses Present/absent Volume/strength Skin perfusion Cap.refill time Temperature Color Mottling CNS perfusion Responsiveness (AVPU) Recognizes parents Muscle tone Pupil size Posturing Slide 18:  Basic Life Support Airway Management : Airway Management OBJECTIVE: Maintain Patent Airway Open Airway Head-tilt/chin-lift method (big tongue, forward jaw displacement critical) Jaw thrust method with possible neck injury Suction Artificial Airways Oropharyngeal Nasopharyngeal Airway Management : Airway Management Head Tilt-Chin Lift Jaw Thrust Avoid extreme hyperextension Breathing : Breathing Look-Listen-Feel Breathing : Breathing Objective: Maintain Gas Exchange Rescue Breathing Mouth to mouth/nose-mouth Bag and Mask Self-inflating Bag-Mask w/o reservoir 30 -80 % O2 with reservoir 60-95 % O2 Do NOT use demand valve Breathing-How much and how fast? : Breathing-How much and how fast? Adequate ventilation= adequate volume x adequate rate Volume: enough to cause chest rise over 1-1.5 sec (esophageal resistance may be overcome if faster) Rate: 20/min synchronized w/ compressions at a ratio of 1:5 Breathing- Adjuncts : Breathing- Adjuncts SIZE PROPER POSITION Oropharyngeal Airway Slide 25: Breathing- Adjuncts Oropharyngeal Airway IMPROPER POSITIONS Nasopharyngeal Airway : Nasopharyngeal Airway Breathing- Adjuncts Bag-Mask Ventilation : Bag-Mask Ventilation Proper area for mask application Breathing Bag-Mask Ventilation : Bag-Mask Ventilation Breathing Bag-Mask Ventilation : Bag-Mask Ventilation Sellick Maneuver Breathing Best Sign of Effective Ventilation : Best Sign of Effective Ventilation Chest Rise Circulation : Circulation How is this achieved by chest compressions? Objective: Maintain adequate blood flow to vital organs Circulation : Circulation Hemodynamics during CPR Heart Compression or Thoracic Pump Model? In children, direct cardiac compression is more likely to be important secondary to the child’s compliant chest. ?compression should be directly over the heart Circulation : In infants ? 1 finger breadth below intermammary line 2 fingers or thumbs encircling At least 100/minute 1/3 to 1/2 of chest Circulation Brachial or femoral pulse is used to check for pulse Circulation : In older children ? the lower third of the sternum Maintain continuous head tilt with hand on forehead One hand 100/minute 1/3 to 1/2 of chest Circulation Carotid pulse is used to check for pulse Slide 35: Circulation-Chest Compressions Indications for chest compression: Absent pulse Heart rate < 60 BPM (or < 80 in infants-Rosen) with signs of poor perfusion Best Sign of Effective Circulation : Best Sign of Effective Circulation Pulse with Each Compression Can CPR cause Retinal hemorrhages? : Can CPR cause Retinal hemorrhages? Retinal hemorrhages are rarely found after chest compressions in patients with nontraumatic illnesses, and those retinal hemorrhages that are found appear to be different from the hemorrhages found in the shaken baby syndrome. Advanced Life Support : Advanced Life Support Vascular Access : Vascular Access Vascular Access Pearls : Vascular Access Pearls Difficult compared to adults. Significant portion of kids respond to AW management alone! Time spent securing a vascular access at the expense of adequate AW management is a common mistake. Drugs can be given through ETT (LEAN). General order of attempts should be: antecubital, hand, or foot and then intraosseous. Intraosseous Cannulation : Intraosseous Cannulation Indication Vascular access required Peripheral site cannot be obtained In three attempts, or After 90 seconds Intraosseous Cannulation : Intraosseous Cannulation Devices 16 gauge hypodermic needle Spinal needle with stylet Bone marrow needle (preferred) Slide 43: Children 6 to 12 years of age: A. Medially to tibial tuberosity B. Above medial malleolus C. Humeral head Children 0 to 6 years of age: A. Medially to tibial tuberosity B. Above medial malleolus 1-3 cm 2-3 cm Intraosseous Cannulation Site Intraosseous Cannulation : Intraosseous Cannulation Needle in place if: Lack of resistance felt Needle stands without support Bone marrow aspirated Infusion flows freely Intraosseous Cannulation : Intraosseous Cannulation Contraindications Fractures Failed attempt on same bone Slide 46: Incomplete penetration of the bony cortex. Penetration of the posterior cortex. Fluid escaping around the needle through the puncture site. Fluid leaking through a nearby previous cortical puncture site. Complications Intraosseous Cannulation What can be put thru an IO? : What can be put thru an IO? Anything that can be put through an IV! Intubation : Intubation Slide 49: Larger in proportion to the oral cavity than in the adult Tongue Epiglottis Larynx Narrower, shorter, omega-shaped 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 between the pediatric and the adult airway Effect Of Edema : Effect Of Edema Poiseuille’s law Intubation : Intubation Failure to oxygenate Failure to ventilate Failure to protect the airway Anticipation of worsening clinical course Indications Tracheal Tube- size and depth? : Tracheal Tube- size and depth? Children > 1 year: ETT size: (Age+16)/4 ETT depth (lip): ETT size x 3 Tracheal Tube : Tracheal Tube Children < 8 years old Small tracheal diameter Narrow cricoid ring ?Uncuffed tubes Tracheal Tube : Tracheal Tube The correct ID tube size is approximately the same size as the end of the patient’s pinky: 1. True 2. False Tracheal Tube : Tracheal Tube 2 studies show that this tenet does not hold true! van den Berg AA, Mphanza T. Choice of tracheal tube size for children: finger size or age-related formula? Anaesthesia. 1997;52:701–703 King BR et al. Endotracheal tube selection in children: a comparison of four methods. Annals Emerg Med. 1993;22:530–534. Laryngoscope Blades : Better in younger children with a floppy epiglottis Straight Laryngoscope Blades Laryngoscope Blades : Laryngoscope Blades Better in older children who have a stiff epiglottis Curved Confirmation of ETT Placement : Confirmation of ETT Placement Seeing tube go through cords Clinical Confirmation Water vapor seen inside tube O2 Saturation Chest rise Equal breath sounds No sounds over epigastrium CO2 Detection / Esophageal Detector Devices Chest X-ray NO single technique is 100% reliable Acute Deterioration after Intubation : Acute Deterioration after Intubation Displacement Obstruction Pneumothorax Equipment failure D.O.P.E: Inadequate Improvement after Intubation? : Inadequate Improvement after Intubation? Inadequate Tidal Volume Excessive Leak Around The Tube Leak or Disconnection in Ventilator System Inadequate PEEP Inadequate O2 Flow from Gas Source Air Trapping and Impaired Cardiac Output Laryngeal Mask : Laryngeal Mask Higher success rate Does NOT protect from aspiration Difficult to maintain during transport Cricothyrotomy : Cricothyrotomy Surgical contraindicated in children <12 Narrowing of trachea at cricoid ring makes procedure hazardous Use needle technique only Slide 64: Drugs Routes for Drugs in CPR : Routes for Drugs in CPR Intravascular Intraosseous Endotracheal (LANE) LIDOCAINE ATROPINE NALOXONE EPINEPHRINE Note: flush each medication with 3-5 ml of NS Oxygen : Oxygen Initiate ASAP Do not delay BLS to obtain oxygen Mouth-to-Mouth ventilation provides only 17% O2 Indicated to all seriously ill or injured patients even if pCO2 is high Use highest possible FiO2 - No risk in short term100% O2 Humidify if possible- avoids plugging airways, adjuncts Slide 67: Epinephrine Dosage IV or IO: 0.01 mg/kg 1:10,000 ET: 0.1 mg/kg 1:1000 Epinephrine Slide 68: Epinephrine Epinephrine is effective in cardiac arrest because: It has direct antiarrythmic effect on fibrillating myocardium. It enhances contractility through its ß1 receptor agonism effect. It increases SVR through its positive action on a1 receptors. Slide 69: Epinephrine Compared to regular dose Epinephrine, high-dose Epinephrine: Improves outcome. Does not change outcome. May worsen outcome. Slide 70: Methods Randomized, double-blind trial. High-dose Epi as rescue therapy for in-hospital arrest after failure of an initial, standard dose of Epi. 68 children, Utstein-style. Primary outcome = survival 24 hours after arrest. Recent updates Results High-dose group tended to have lower 24-hour survival rate (OR for death, 7.9; 97.5 CI 0.9-72.5; P=0.08). No difference in ROSC (OR 1.1; 97.5 CI 0.4-3.0). None in the high-dose group, as compared with 4 in the standard-dose group, survived to hospital discharge. A Comparison of High-Dose and Standard-Dose Epinephrine in Children with Cardiac Arrest NEJM 350;17 April 22, 2004 Slide 71: Calcium In infants, cardiac contractility depends on extracellular calcium influx since intracellular calcium is deficient. ?hypocalcemia can present with cardiogenic shock! There is no role for the empiric use of calcium. Indications for use: Correct documented hypocalcemia. Antagonise hyperkalemia and hypermag. CCB toxicity. Dose: CaCl2 10% (100 mg/ml) 20 mg/Kg IV Sodium Bicarbonate : NaHCO3 (1 mEq/ml) Sodium Bicarbonate 1 mEq/kg IV Slide 73: Sodium Bicarbonate All of the following are true EXCEPT: NaHCO3 inactivates catecholamines. NaHCO3 leads to increased CO2 production and worsening acidosis. No evidence shows an improvement in outcome when NaCO3 in administration during resuscitation from cardiac arrest. Attendance to rounds in negotiable by Ken. Atropine : Atropine 0.02 mg/kg IV or IO Double ET dose Minimum dose: 0.1 mg to avoid paradoxical bradycardia Maximum single dose: Child: 0.5 mg Adolescent: 1mg Slide 75: Atropine All of the following are true regarding Atropine EXCEPT: It increases SA and AV conduction through muscuranic antagonism. At low doses, it has central and peripheral parasympathomimetic actions which may lead to paradoxic vagotonic effects. In children, it is used to treat bradycardia empirically. It does not cause fixed and dilated pupils during cardiac arrest. What about Vasopressin? : What about Vasopressin? Vasopressin : Vasopressin 2000 AHA/ILCOR guidelines: insufficient data to make any recommendations. Nadkarni et al. Beneficial effects of vasopressin in prolonged pediatric cardiac arrest: a case series Resuscitation 2002; 52:149-156 Retrospective case series of 4 patients only! Electricity and Arrhythmias : Electricity and Arrhythmias Electricity : Electricity 90% of pediatric cardiac arrest is Asystole, or Bradycardic PEA ?Defibrillation seldom needed Electricity : Electricity Paddle diameter: Infants: 4.5 cm Children: 8.0 cm Largest paddles that contact entire chest wall without touching If pediatric paddles unavailable, use adult paddles with A-P placement Defibrillation : Defibrillation Energy Settings Initial: 2 J/kg Repeat: 4 J/kg Cardioversion : Cardioversion Energy settings: Initial: 0.5 - 1.0 J/kg Repeat: 2.0 J/kg Cardiovert only if signs of decreased perfusion Arrhythmias : Arrhythmias Tachycardias Sinus Bradycardia Pulseless Electrical Activity Asystole Ventricular Fibrillation Ventricular Tachycardia PEA : PEA Any organized rhythm without a detectable pulse (except VT) Treat like asystole with consideration of reversible causes Asystole : Asystole Rate: complete absence of any ventricular activity P waves: in some cases P waves may be seen Pulse: ABSENT Slide 86: Asystole/PEA ? Tachycardias : Tachycardias Narrow-complex tachycardia, rate < 200 Usually sinus tachycardia Do not cardiovert Look for treatable underlying cause Sinus Tachycardia : Sinus Tachycardia Fever Shock Pain Hypovolemia Hypoxia Drugs Cardiac tamponade Causes Tachycardias : Tachycardias Usually supraventricular tachycardia Rhythm is REGULAR P waves may be difficult to see QRS is narrow Frequently associated with congenital conduction abnormalities If no conversion after two shocks, consider possibility rhythm is sinus tachycardia Narrow-complex tachycardia, rate > 230 Supraventricular Tachycardia : Supraventricular Tachycardia Stable ? Adenosine 0.05 - 0.1 mg/Kg IV Unstable ? Synchronized Cardioversion Slide 91: SVT Sinus Bradycardia : Sinus Bradycardia Rate: less than 60 BPM Rhythm: regular P waves: upright QRS: following each P wave Sinus Bradycardia : Most bradycardias respond to Oxygen Ventilation For bradycardia 2o to hypoxia/ischemia, preferred first drug is epinephrine Sinus Bradycardia Slide 94: Bradycardia ;k * *not an AHA recommendation! Slide 95: Update: 2000 AHA/ILCOR guidelines VF : VF Rate: rapid, usually too disorganized to count Rhythm: irregular, wave forms vary in size and shape NO P waves, QRSs, ST segments, or T waves discernable Pulse: ABSENT VF : VF Electrolyte imbalances Drug toxicity Electrical injury Pediatric VF suggests Slide 98: Ventricular Fibrillation/VT Amio. 5mg/kg bolus IV/IO or Lido. 1 mg/kg bolus IV/IO/PT or Mg 25-50 mg/kg IV/IO for TDP or hypomag. ? Slide 99: What is the rhythm? VT : VT Rate: close to normal to more than 400 Rhyhm: usually regular P waves: often not recognizable QRS: wide VT : VT Pulseless treat as VF Pulse present Stable Amiodarone 5mg/kg Procainamide 15mg/kg Lidocaine 1 mg/kg Unstable Synchronized Cardioversion Questions : Questions

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