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Pediatric Cardiopulmonary Resuscitation Isabel Porto, PharmD Clinical Pharmacist for Pediatrics Assistant Clinical Professor Department of Pharmacy Practice College of Pharmacy University of Illinois at Chicago University of Illinois at Chicago Clinical Pharmacist Pediatrics Learning objectives Learning objectives • Review the American Heart Association Pediatric Advance Life Support (PALS) Guidelines • Review the treatment algorithms used in pediatric Review the treatment algorithms used in pediatric cardiopulmonary resuscitation • Discuss drug administration via the endotracheal tube and g intraosseous route • Review the use of emergency drugs during pediatric resuscitation i i • Review medications used in neonatal resuscitation • Discuss the role of the pharmacist during pediatric Discuss the role of the pharmacist during pediatric cardiopulmonary arrest Introduction • Incidence (USA) I id (USA) • 16,000 children die each year from cardiopulmonary arrest • Children account for 10% of out of hospital arrests • Age • Over half are less than 1 year old • Etiology • Differs from adult arrest • SIDS, trauma, submersion, cardiac diagnosis, sepsis, SIDS trauma submersion cardiac diagnosis sepsis toxic ingestion Introduction • Respiratory vs. Cardiac arrest • In most infants and small children respiratory arrest precedes cardiac arrest cardiac arrest • Early recognition and intervention prevents progression to cardioopulmonary arrest • Respiratory arrest is associated with a better prognosis • Only 10% of children survives cardiopulmonary arrest Airway Anatomy and Physiology Airway Anatomy and Physiology • Infant tongue is proportionately large • Subglottic airway is smaller and more compliant • easily obstructed easily obstructed • Limited oxygen reserve Cardiac Output, Oxygen Delivery, and Cardiac Output Oxygen Delivery and Oxygen Demand • Cardiac output is dependent on maintenance of an adequate heart rate in pediatrics p • CO = HR x SV • Bradycardia may be associated with a rapid fall in cardiac output Development of the Pediatric ALS Guidelines (PALS) • American Heart Association published first guidelines in 1986 bl h d f d l • Last revisions made in 2005, 2010 • International conference on CPR and emergency cardiovascular care International conference on CPR and emergency cardiovascular care (ECC) created in 2000 • Produce international resuscitation guidelines • Classes of recommendations (Class I, II a, II b, indeterminate and III) • Guidelines for pediatrics rarely reach a high level of Guidelines for pediatrics rarely reach a high level of recommendation • Most are indeterminate, none of the guidelines are class I Levels of Recommendation Class 1 Recommendations are always acceptable. They are proven safe and definitely useful. Supported by evidence from at least 1 prospective, randomized clinical trial Class 2a Recommendations considered acceptable with good to very good evidence providing support. The weight of evidence and expert opinions strongly favors these interventions Class 2b Recommendations considered acceptable and useful with weak or only fair evidence providing support. Class 3 Refers to recommendations that are unacceptable Class Indeterminate Refers to an intervention that is promising , but the evidence is insufficient in quantity and/or quality to support a definitive class of recommendation Estimating Patient Weight in an Emergency Estimating Patient Weight in an Emergency • Weight based dosing of fluids and medications • Out –of – hospital and emergency department settings weight may be unknown Skilled personnel may not accurately estimate • Skilled personnel may not accurately estimate weight based on appearance • Growth chart is impractical Growth chart is impractical • Length is easily measured • Tapes to determine weight from length are available d h f l h l bl Broselow tape Bradycardia • The most common dysrhythmia in pediatric population • Definition • Heart Heart rate < 60 BPM or rate < 60 BPM or • Rapidly dropping heart rate despite adequate oxygenation and ventilation associated with poor perfusion • Causes • • • • • • Hypoxemia, Hypothermia, Hypotension, Hypoglycemia Excessive vagal stimulation Central nervous system Drug induced Drug induced Inflammatory injury Cardiac surgery Normal Heart Rates Age Mean Heart Rate Heart Rate Range (2nd – 98th percentile) < 1 day 123 93 – 154 1 – 2 days 123 91 – 159 3 – 6 days d 129 91 – 166 1 – 3 weeks 148 107 - 182 1 – 2 months 149 121 - 179 3 – 5 months 141 106 - 186 6 – 11 months 134 109 - 169 1 – 2 years 119 89 - 151 3 – 4 years 108 73 - 173 5 – 7 years 100 65 - 133 8 – 11 years 91 62 - 130 12 – 15 yyears 85 60 - 119 PALS Bradycardia Algorithm Circulation 2005;112:IV-167-IV-187 Copyright ©2005 American Heart Association Treatment of Bradycardia y (see algorithm) E i Epinephrine hi Remember there are two concentrations 1:1,000 (1mg/ml) and a 1:10,000 (0.1mg/ml) , ( g/ ) , ( g/ ) IV/IO: 0.01mg/kg (1:10,000; 0.1ml/kg) Endotracheal dose: 0.1mg/kg (1:1,000; 0.1ml/kg) Treatment of Bradycardia Treatment of Bradycardia • Atropine • An anticholinergic • Accelerates sinus or atrial pacemakers Accelerates sinus or atrial pacemakers • Increases AV nodal conduction • Indications • Vagally mediated bradycardia • Symptomatic bradycardia with primary AV block Atropine Dosing Atropine Dosing • 0.02mg/kg IV/IO / / • Minimal dose is 0.1mg • Smaller doses may cause paradoxical bradycardia S ll d d i lb d di • Infants < 5kg the minimal dose is not established • Maximum dose M i d • Child = 0.5mg • Dose may be repeated once D b d • ET dose = 0.04 – 0.06 mg/kg Atropine p • Available products (USA) p ( ) • Concentration 0.1mg/ml • 5ml & 10ml syringes • Concentration 1mg/ml / • 1ml vials • Concentration 0.4mg/ml Concentration 0.4mg/ml • 1ml vials • Hong Kong availability? • Careful when calculating volume Treatment of Asystole/PEA Treatment of Asystole/PEA • Asystole • No rhythm, No pulse • PEA: Pulseless Electrical Activity • • • • Electrical activity on monitor y Absence of pulse (cardiac output) Pre ‐ terminal rhythm Treat reversible causes PEA Reversible Causes • 4 H’S • • • • Hypovolemia Hypoxemia Hypothermia Hyperkalemia • 4 T’s • • • • Tension Pneumothorax Pericardial tamponade Toxins Thromboembolus Asystole • ABC’s • Airway • Breathing • Circulation (Chest Compressions) • Epinephrine p p • Every 3 ‐ 5 minutes PALS Pulseless Arrest Algorithm Circulation 2005;112:IV-167-IV-187 Copyright ©2005 American Heart Association Epinephrine • Endogenous catecholamine with a and β adrenergic effects • a effects (vasoconstriction) most important in arrest • Increase SVR • Increase aortic diastolic pressure • Increase blood flow to the myocardium and coronary arteries Increase blood flow to the myocardium and coronary arteries increasing the coronary perfusion pressure • Enhances delivery of oxygen to the heart Epinephrine • Other effects of epinephrine • Enhances the contractile state of the heart • Stimulates spontaneous contractions • Increases the success of defibrillation • Indications • Cardiac arrest • Symptomatic bradycardia Symptomatic bradycardia unresponsive to unresponsive to ventilation and oxygen administration • Hypotension unrelated to volume depletion Hypotension unrelated to volume depletion Epinephrine • Dosing IV/IO for asystole / • Remember there are two available concentrations • 1:1000 • 1:10,000 • 0.01mg/kg/dose • 0.1ml/kg of the 1:10,000 • Second and subsequent doses • 0.01mg/kg/dose 0 01mg/kg/dose • 0.1ml/kg using the 1:10,000 product Epinephrine p p • Controversial dosing before 2005 guidelines update • Escalating dose if initial is ineffective • 0.1 ‐ 0.2mg/kg/dose • Use the 1:1,000 product • Initial investigations demonstrated benefit g • Further trials failed to demonstrated benefit • Adverse effects of high dose epinephrine g p p • Increased myocardial oxygen consumption, myocardial necrosis, post ‐ arrest dysfunction, post ‐ arrest hyper‐adrenergic state • HIGH DOSE NO LONGER RECOMMENDED Epinephrine Continuous Infusion Epinephrine Continuous Infusion • Indications • Refractory bradycardia • 0.1 0 1 ‐ 0.2 mcg/kg/min titrated to effect 0 2 mcg/kg/min titrated to effect • Used after spontaneous circulation is restored in asystole • 0.1 ‐ 1mcg/kg/min titrated to effect • Low‐dose infusions ( <0.3 mcg/kg/minute) generally produce beta‐adrenergic actions (tachycardia, potent inotropy, and decreased systemic vascular resistance) decreased systemic vascular resistance). • Higher‐dose infusions ( > 0.3 mcg/kg/per minute) cause alfa‐ adrenergic vasoconstriction. g • Compatible in 0.9% Sodium Chloride and Dextrose solutions • Preferably given via a central placed catheter Epinephrine Continuous Infusion Epinephrine Continuous Infusion • Considerations/Adverse effects / • Infiltration may cause tissue ischemia leading to injury and ulceration • Inactivated in sodium bicarbonate. Flush with saline in between doses • Causes tachycardia • High dose infusion may cause excessive vasoconstriction • May compromise extremity, mesenteric and renal blood flow May compromise extremity mesenteric and renal blood flow Ventricular Fibrillation Ventricular Tachycardia • Uncommon in children • • • • Congenital heart disease Cardiomyopathies Drug toxicity Metabolic causes PALS Pulseless Arrest Algorithm Circulation 2005;112:IV-167-IV-187 Copyright ©2005 American Heart Association VF/VT Treatments / See algorithm • Pulseless Pulseless VF/VT VF/VT • Defibrillation • • • • “shocks” untimed depolarization of the myocardium D fi iti th Definitive therapy for pulseless VF and VT f l l VF d VT Administer 1 shock initially at 2 J/kg then resume CPR immediately Subsequent shocks are 4 J/kg • Epinephrine • Immediately after rhythm check during CPR every 3 to 5 minutes • Amiodarone • Immediately after rhythm check during CPR I di t l ft h th h k d i CPR • Pattern should be Shock, CPR, Check, CPR (While preparing defibrillator) Shock (Drug while giving CPR ) defibrillator),Shock,(Drug while giving CPR ) Amiodarone Amiodarone • Non ‐ competitive inhibitor of both a and β receptors • Slows AV conduction and prolongs AV refractory period (slows ventricular conduction) ventricular conduction) • IV administration produces AV nodal suppression Inhibits the outward potassium current which prolongs the QT • Inhibits the outward potassium current which prolongs the QT interval • Inhibits sodium channels (dependent) Amiodarone • 5mg/kg rapid IV over 10 minutes for pulseless VF/VT 5 /k id IV 10 i t f l l VF/VT • If stable infuse over 20 ‐ 60 minutes • Maximum dose is 15mg/kg/day • Compatible with Dextrose solutions • Maximum concentrations 1‐ 6 mg/mL • Adverse reactions Adverse reactions • • • • • • Hypotension Interference with thyroid hormone metabolism Interstitial pneumonitis, pulmonary fibrosis, ARDS Corneal micro deposits Elevated liver enzymes Elevated liver enzymes Blue gray skin discoloration • Should not be given with procainamide (increases QT inter al) itho t ad ise of cardiologist interval) without advise of cardiologist VF/VT other treatments VF/VT other treatments • Lidocaine: not as effective as amiodarone • Give if amiodarone not available • Vasopressin (adults) • Not enough evidence in pediatric patients • Magnesium Sulfate • Hypomagnesemia • Torsades de Pointes Lidocaine • Suppresses ventricular arrhythmias by decreasing automaticity • Not as effective as amiodarone • Dosing is 1mg/kg as a rapid injection D i i 1 /k id i j ti • Follow with an infusion of 20 ‐ 50 mcg/kg/min • Available as premade solution for continuous drip Available as premade solution for continuous drip • Toxicity • Myocardial and circulatory depression y y p • CNS symptoms: drowsiness, disorientation, muscle twitching, seizures Vasopressin • N Naturally occurring antidiuretic hormone t ll i tidi ti h • Peripheral vasoconstriction of skin, skeletal muscle and fat. • Vasodilatation of the cerebral vasculature • Not affected by acidosis • Adults Adults • Can be used as an alternative to epinephrine for adult shock refractory VF • Results in adults are also inconsistent R l i d l l i i • Limited information in pediatrics p • Not routinely used Tachycardias • Ventricular tachycardia (wide QRS ) V ti l t h di ( id QRS ) • Cardioversion • First attempt: 0.5 to 1 J/kg • Second attempt: 2 J/kg p g • Adenosine • Amiodarone • Procainamide Supraventricular Tachycardia Supraventricular Tachycardia • M Most common non – t l th l h th i lethal rhythm in pediatrics di t i • Attempt vagal stimulation first • If patient is stable chemical and IV access If patient is stable chemical and IV access • Chemical cardioversion with adenosine • If patient is unstable and IV access not readily available, provide synchronized cardioversion id h i d di i • Consider amiodarone or procainamide for SVT unresponsive to vagal maneuvers and adenosine g PALS Tachycardia Algorithm Circulation 2005;112:IV-167-IV-187 Copyright ©2005 American Heart Association Adenosine • Endogenous nucleoside • Blocks conduction through the AV node • Dosing •0 0.1mg/kg (Maximum 6mg 1 1mg/kg (Maximum 6mg 1st dose) • If first dose is ineffective 2nd dose is 0.2mg/kg (Max of 12mg) of 12mg) • Infuse as centrally as possible, because of fast degradation • Follow with a saline flush Procainamide • Sodium channel blocking antiarrythmic • Dosing: 15mg/kg over 30 ‐ g g/ g 60 minute • May be considered in children with perfusing rhythm y • Requires slow infusion and continuous monitoring • Monitor EKG • To monitor for heart block, myocardial depression and prolongation of the QT • If QRS widens to >50% of baseline or hypotension occurs stop the i f i infusion • Do not use routinely with amiodarone Other Emergency Medications Other Emergency Medications • Sodium Bicarbonate • Dextrose • Calcium Salts C l i S lt Sodium Bicarbonate Sodium Bicarbonate • Indications • Acidosis resulting from prolonged cardiac arrest • Documented severe metabolic acidosis • Hyperkalemia • Tricyclic antidepressant overdose • Dosing • 1mEq/kg IV or IO • Repeat doses 0.5mEq/kg Repeat doses 0 5mEq/kg • Infants less than 3 months use the 0.5mEq/ml • 0.5meq/ml is the 4.2% solution or the 8.4% solution diluted 1:1 q with sterile water for injection • Incompatible with other medications • Flush with normal saline in between drugs Fl h ith l li i b t d Sodium Bicarbonate Sodium Bicarbonate • Considerations /Adverse effects / • • • • • Metabolic alkalosis Hyperosmolarity Hypernatremia Inactivates catecholamines Precipitates with calcium salts Dextrose • ** ** Dextrose containing fluids not used for fluid Dextrose containing fluids not used for fluid resuscitation** • Infants have a high glucose requirement and low glycogen stores Infants have a high glucose requirement and low glycogen stores • Neonatal hypoglycemia • No data to support administration during resuscitation pp g • Correct hypoglycemia after resusitation • Dextrose 10% 2ml/kg slow iv push (0.2gm/kg) • Pediatric hypoglycemia P di i h l i • Dextrose 50% 1 ‐ 2 ml/kg slow iv push • Dilute with equal volume of sterile water for injection q j • Adult dose is 50 ml of dextrose 50% or 25gms Calcium Salts Calcium Salts • Indications • • • • Hypocalcemia Hyperkalemia Hypermagnesemia Calcium channel blocker overdose •D Dosing ‐ i calcium chloride contains 3xs the amount of l i hl id t i 3 th t f elemental calcium ++ • Calcium chloride 27mg/ml elemental CA g/ • 20 ‐ 25 mg/kg (0.2 ‐ 0.25ml/kg) • Calcium Gluconate 9mg/ml elemental CA++ • 60 60 ‐ 100 mg/kg (0.6 100 mg/kg (0 6 ‐ 1ml/kg) Intravascular Fluids Intravascular Fluids • Critical in trauma patients • Non ‐ traumatic shock • Isotonic crystalloid solutions preferred over colloid • Ringers lactate or Normal Saline • Dextrose containing solutions should not be used Dextrose containing solutions should not be used • Hyperglycemia before cerebral ischemia worsens neurological outcome neurological outcome • 20 mL/kg IV push, repeat as needed for perfusion Alternative Routes of Administration • ≤ 6 years old after 90 seconds or 3 attempts if venous access not obtained consider alternative route • Intraosseous • • • • Proximal tibia or distal femur Fluids, drugs, blood Onset of action for drugs comparable to venous administration Follow each medication with a saline flush Alternative Routes of Administration • Endotracheal • Absorption across the terminal bronchioles and alveoli • • • • Lidocaine Epinephrine Atropine Naloxone • Dilute medications in up to 5ml of NS and follow by 5 manual ventilations • May need to administer medications at 2 ‐ May need to administer medications at 2 ‐ 2.5 times the 2 5 times the recommended dose • The dose for epinephrine is 10xs the recommended dose. • 0.1mg/kg (0.1ml/kg of the 1:1,000 dilution) Neonatal resuscitation Neonatal resuscitation • Medication administration via umbilical vein • Preferred route for IV access • Alternative routes Alternative routes • Endotracheal tube • Intraosseous Neonatal resuscitation Epinephrine • Indication • • • • heart rate < 60 beats per minute 30 seconds assisted ventilation 30 seconds assisted ventilation 30 seconds coordinated compressions and ventilation Do not use epi before adequate ventilation is established • Concentration • 1:10,000 • Recommended dose • 0.1 to 0.3 mL/kg IV push • ET administration: 0.3 to 1 mL/kg ET d i i t ti 0 3 t 1 L/k Neonatal resuscitation Epinephrine • Poor response with HR < 60 bpm • Recheck effectiveness of • • • • • Ventilation Endotracheal intubation Chest compressions p ?Hypovolemia Epinephrine delivery Neonatal resuscitation Blood volume expansion • Normal saline first line • Lactate Ringer’s • O RH‐negative O RH negative blood • Dose • 10 mL/kg over 5 to 10 minutes / g • May be repeated if hypovolemia persists • Draw correct volume into a syringe • Expected response • • • • Increased heart rate Stronger pulses l BP increases Less pallor Less pallor Role of pharmacist Role of pharmacist • Preparation of individualized doses • Pre calculated emergency drug sheets • Others Oth
