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Kristen Johnson Adam Oster PEDIATRIC AND NEONATAL RESUSCITATION Objectives Highlight differences between pediatric and adult cardiac arrest regarding Etiology Outcomes Practice the basics of pediatric resuscitation through a variety of cases Provide numbers and tips to help in a crunch Review controversial areas of resuscitation Not little adults? Newly Born – in delivery room, including first few hours of life Newborn – delivery until discharge from hospital/NICU Infant – initial discharge from hospital until 12 months Child – 1 year old until adolescence (signs of puberty) Adult – adolescent (signs of puberty) and older Respiratory Distress Hypoxemia Hypercapnea Acidosis Circulatory Compromise Respiratory Failure Bradycardia Hypotension Circulatory Failure 80% Cardiac Arrest 20% Airway intervention saves 90% IV access saves 9% Drugs save 1% Etiology Out of Hospital Trauma (1/3) Blunt trauma Drowning Fire Residential accidents Strangulation Medical (2/3) SIDS Respiratory Disease Cardiac disease/arrhythmia CNS disease Toxins Sepsis Metabolic Gerein et al. Acad Emerg Med 2006 Young et al. Pediatrics 2004 Incidence of Out of Hospital Cardiac Arrest Adolescents • 6/100 000 person years Infants • 72/100 000 person years Adults • 126/100 000 person years Children • 4/100 000 person years Atkins et al. Circulation 2009 Survival Following Out of Hospital Cardiac Arrest Children 9.1% NNT = 10 Infants 3.3% NNT = 29 Adolescents 8.9% NNT = 8 Adults 4.5% NNT = 13 Atkins et al. Circulation 2009 VF arrests Occurs in 5% of infants/children 15% of adolescents Survival in VF (20%) >> than PEA/asystole (5%) Mortality increases by 7-10% per minute of delay to defibrillation Atkins et al. Circulation 2009 Predictors of increased survival Peri-arrest Witnessed arrest* Post-arrest Absence of Weekend arrest Rhythm other than asystole No atropine or HCO3 Fewer epi doses Shorter duration of CPR Drowning/submersion* or asphyxial arrest pressors/inotropes Greater lowest pH Low lactate Lower maximum glucose N pupilllary responses Higher lowest temperature Moler et al. Crit Care Med 2011 *Donaghue et al. Ann Emerg Med 2005 Unresponsive in crib this morning To cuff or not to cuff…. Higher likelihood of correct selection of tube size No greater risk of post-extubation stridor May decrease risk of aspiration Beneficial when high ventilation pressures required Newth et al. J Pediatr 2004 Weiss et al. Br J Anaesth 2009 Any role for intratracheal epi? Maybe Probably Not Is there a role for high dose epinephrine? coronary artery perfusion cerebral artery perfusion myocardial O2 consumption “Less is more…” “There is no survival benefit from high dose epinephrine, and it may be harmful, particularly in asphyxia.” Dieckmann et al. Pediatrics 1995 Carpenter et al. Pediatrics 1997 Perondi et al. NEJM 2004 Patterson et al. Pediatr Emerg Care 2005 Family presence during resuscitation Patient perspective • ??? Family perspective • overwhelmingly positive Clinician perspective • mixed thoughts Families should be allowed in the resuscitation room. Families Clinicians Majority want to be Family presence does not present Most do not regret their decision to be present Positive trend in psychological health Less anxiety/depression Fewer disturbing memories Eased grief delay or interfere with care Procedural performance is not affected Some have performance anxiety Some have medical-legal concerns Nurses > Physicians > Trainees in willingness to include families Tinsley et al. Pediatrics 2008 ???When to call it??? >3 doses of epinephrine > 30 minutes of CPR in ED Exceptions: Primary cardiac disease and ECMO available Hypothermia Suspected toxicologic cause Young et al. Pediatrics 2004 Moler et al. Crit Care Med 2011 Raymond et al. Pediatr Crit Care Med 2010 Morris et al. Pediatr Crit Care Med 2004 Called STAT overhead 18 month old Unwell for 3-4 days Fever Cough resp distress Should we cool our patient? Adults Neonates Pediatrics ? Fink et al. Pediatr Crit Care Med 2010 Doherty et al. Circulation 2009 7 year old girl Unwell for 1 week Flu-like illness Low grade fever What is the best energy dose for defibrillation? 2 J/kg likely too low 3-5 J/kg may be better No more than 10 J/kg PALS = 2 - 4 J/kg with 4 J/kg for subsequent shocks Anterior-posterior position likely better than Anterior-lateral position Tibballs et al. Pediatr Crit Care Med 2011 Calcium associated with worse outcomes Survival 21% vs. 44% Favorable neuro outcome 15% vs. 35% Exceptions electrolyte abnormalities toxicological abnormality Srinivasan et al. Pediatrics 2008 Bicarbonate not indicated in routine resuscitation Meert et al. 2009 Multi-center cohort study that found HCO3 administration associated with increased mortality Lokesh et al. 2004 RCT showing no survival benefit in neonates resuscitated with bicarbonate 17 year old brought in from drug house Abdominal pain Thinks may be pregnant 10% of newborns will require some assistance after birth <1% require extensive measures <0.1% require chest compressions < 23 weeks GA Anencephaly Known trisomy 13 Birth weight <400g <29 wk GA Cover with plastic Begin resuscitation with room air M reapply Mask R Reposition head S O P A Suction mouth and nose Open mouth increase Pressure Alternate airway Time Saturation 1 min 60-65% 3 min 70-75% 5 min 80-85% 10 min 85-95% Compression:Breath ratio = 3:1 Terminate after 10 minutes of good CPR THANKS
