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6/24/2013
Concepts and Controversies in
Pediatric CPR
Arno Zaritsky, MD
Children’s Hospital of The King’s Daughters; Norfolk, VA
Disclosures
 I am a non-compensated consultant on the
Broselow-Luten color-coded dosing system
 I chair the DSMB for the NIH-funded trial of
Therapeutic Hypothermia After Pediatric Cardiac
Arrest (THAPCA)
 Note that some treatments (eg, therapeutic
hypothermia & amiodarone for pediatric cardiac
arrest) in AHA Guidelines are not yet approved by
the FDA
Unlearning – a new
challenge
 Introducing new guidelines every 5 years requires
that you must “unlearn” something that you learned
 Learning something new is easy
 Unlearning requires that you alter your current
knowledge and deal with conflicts between new and
old information
 Our brains are not like a computer hard drive
 Unlearning is hard work!
Johnson, C. Unlearning, BMJ 2005; 331:703
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A concerted attempt to separate
A,B and C!
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CPR Sequence
 Change:
 From A-B-C to C-A-B
 Initiate chest compressions
before ventilations
 Why?
 Goal: To reduce delay to
CPR, sequence begins with
skill that everyone can
perform
 Opening airway and
delivering rescue breaths
most difficult procedure for
rescuers
 Standardize training
© 2010 American Heart Association. All rights reserved.
Pediatric Basic Life Support
 C-A-B rather than A-B-C sequence
 Traditional CPR (compressions and ventilations) by
bystanders associated with higher survival than chest
compressions alone (see Lancet 2010; 375:1347)
 Unknown if it makes a difference if sequence begins
with ventilations (ABC) or compressions (CAB)
 C-A-B recommended to simplify training
 Doing 30 compressions should delay ventilations by 18
secs or less, esp. if 2 rescuers
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Pediatric Advanced Life
Support (PALS)
 Foundation of successful PALS is high quality BLS –
change to C-A-B.
 Traditional cardiac arrest algorithm simplified with
emphasis on the importance of high-quality CPR.
 Role of medications questioned
 Increased emphasis on continuous waveform
capnography to
 verify endotracheal tube placement
 optimize CPR quality and detect ROSC
Quality of CPR During InHospital Cardiac Arrest
 Case series n=67
 U of Chicago
 Chest compressions were too slow
 38% of compressions were too shallow
 Ventilation rates were too high (>20/min
in 61%)
 24% of time with no compressions
Abella B, JAMA 2005; 293:305-310
Milander M, Arch
Int Med 1995
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Chest Compressions
Aufderheide T, et al. Incomplete
chest wall decompression.
Resuscitation 2005; 64:353-62.
Yannopoulos D, et al. Resuscitation
2005; 64:363-72.
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Interruptions kill: The CPP story
Aortic diastolic
pressure
Coronary perfusion pressure = Ao Diastolic – RA pressure
Sarver Heart Center Resuscitation Research Team
Chest Compressions
Critical
 Without effective chest compressions
 Oxygen flow to brain stops
 Oxygen flow to heart stops
 Drugs go nowhere.
 Important to relax chest pressure completely – no
leaning!
 Minimize interruptions in chest compressions
Direct Compression
Kao P‐C, et al. Pediatrics 2009; 124:49‐55
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Compression Depth
 Currently recommend compressing
at least 1/3 A-P diameter
 In most infants, compression depth of 3.8 cm achieves at
least 1/3 A-P diameter
 How do you teach this?
 Devices can provide feedback, but movement of
bed/mattress affect reading; recent data suggest that
up to 40% of compression depth is from mattress
compression
Sutton RM et al. Resuscitation 2009; 80:1137-41; Braga MS et al.
Pediatrics 2009; 124:e69-e74; Kao P-C et al. Pediatrics 2009; 124:49-55
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Effective chest compressions
 “Push Hard and Push Fast” at 100/min
 Is faster better?
 Allow chest to recoil
 Limit chest compression interruptions
 Use 30:2 C:V ratio for single rescuer and 15:2 C:V
ratio for two rescuers
Staying Alive
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Adverse Effects of
Ventilation
 Noted high ventilation
rates by EMS providers
(~30/min)
Review of 68 peds sim codes showed mean ventilation rate of  Study
in pigs showing
40.6 ± 11.8 bpm. effects
of ventilation
For isolated respiratory arrest, mean rate
on mean
rate was 44 ±
13.9 bpm. intrathoracic pressure
Pediatrics
2011; 128:e1195‐1200
(MIP), coronary
perfusion pressure
(CPP) and survival
 9 pigs/group studied
Aufderheide TP, Sigurdsson G, Pirrallo RG, et
al. Hyperventilation-Induced Hypotension
During Cardiopulmonary Resuscitation.
Circulation 2004; 109:1960-5
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Tidal Volume and
Ventilation Rate
Review of 68 peds sim codes showed mean ventilation rate of 40.6 ± 11.8 bpm. For isolated respiratory arrest, mean rate was 44 ± 13.9 bpm. Pediatrics 2011; 128:e1195‐1200
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Intubation: Cricoid Pressure
 Recent data show that
modest pressure can distort
the pediatric and adult
airway
 No data show that cricoid
pressure effectively
prevents aspiration
 If used, abandon if
ventilation or visualization is
impaired
Walker RWM, et al. Br J Anaesth 2010; 104:71‐74. Ellis DY, et al. Ann Emerg Med 2007; 50:653‐665.
Cuffed vs. Uncuffed ET
tube
 Traditionally, uncuffed tubes are used in children
<8 yrs of age to avoid subglottic injury
 Large in-hospital case series, however, did not show a
higher morbidity with cuffed ET tubes in young
children – BUT requires proper monitoring of cuff
pressure
 Consider using a cuffed ET for resuscitation in
children with:
 High airway resistance (severe asthma)
 Poor lung compliance anticipated (aspiration
pneumonia)
 Large glottic air leak
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Cuffed vs. Uncuffed ET
tube
 Cuffed tubes are safe, when used
properly
 Monitor cuff pressure – keep
< 20-25 cm H2O
 Formula: 3.5+(age/4) for children
> 2 yrs of age
 3.0-3.5 mm < one year
 3.5 – 4.0 mm for one-two years old
 Length-based estimate is superior
to age-based estimate
Waveform Capnography
 Change:
 Quantitative waveform capnography is the most reliable
method to confirm and monitor correct ET tube placement.
 Why:
 Unacceptably high incidence of unrecognized ET tube
misplacement or displacement.
 Capnography has high sensitivity and specificity to identify
correct endotracheal tube placement in cardiac arrest.
 Can be used for monitoring CPR quality and detecting
ROSC
ACLS & PALS: Waveform
Capnography
 After intubation, exhaled carbon dioxide is detected,
confirming tracheal tube placement.
 Highest value at end-expiration.
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Exhaled CO2 =
10-15 torr
PaCO2 = 25 torr
Under steady state
conditions (constant
minute ventilation), ETCO2
is determined by VCO2,
effective pulmonary blood
flow and physiologic dead
space
PvCO2 = 100 torr
 Animal data consistently
show a relationship
between ETCO2 and
cardiac output, provided
minute ventilation is
relatively constant
 In children with increased
RL shunts that reduces
pulmonary blood flow
ETCO2 will fall
Animated GIF from www.capnography.com
Physiologic Monitoring
During CPR
Adult data show that failure to achieve ETCO2 >10 to 15 mmHg
is associated with failure to achieve ROSC. Monitoring ETCO2
during CPR may help to guide quality of CPR and substitute for
need to pause to conduct pulse checks
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Witnessed collapse
outside store and CPR
started by 2 firefighters
who saw arrest.
At 34 mins ETCO2
was in low 30’s and
maintained there
during CPR so
rescuers continued
efforts.
He received a total of
12 shocks and came
out of VF after
amiodarone. Had good
neurologic outcome.
WSJ – May 17, 2011
© 2010 American Heart Association. All rights reserved.
An ETCO2 of ≤1.9 kPa (14.3 mmHg) measured at 20 mins after
the initiation of ALS for cardiac arrest accurately predicts death in
adult OOH cardiac arrest.
For ROSC, the sensitivity, specificity, PPV and NPV were all
100% using this threshold at 20 mins.
ETCO2
> 1.9 kPa (14.3 mmHg)
≤ 1.9 kPa
ROSC
402
0
No ROSC
0
335
Initial ETCO2 is higher with asphyxial versus cardiac arrests.
ETCO2 decreases transiently after epinephrine and increases
transiently after sodium bicarbonate
Kolar M, et al. Crit Care 2008; 12:R115
© 2010 American Heart Association. All rights reserved.
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Defibrillation Dose
 Optimal energy dose is unknown; data from NRCPR
found low first shock success rate for 2 and 4 J/kg
(53%) in-hospital*
 Lower success with 4 J/kg, but may be selection bias
 Biphasic energy (up to 10 J/kg) safer than
monophasic doses in animal models
 Manual defibrillator preferred; use AED in children if
that is all you have
 Note: primary VF/VT has good outcome; secondary
VF/VT associated with poor outcome
*Meaney PA, et al. Pediatrics 2011; 127:e16-e23
Olasveengen, T. M., K. Sunde, et al. "Intravenous Drug Administration During Out‐of‐Hospital Cardiac Arrest: A Randomized Trial." JAMA 2009; 302:2222‐9.
 Prospective RCT of non-traumatic CA over 5 years in
Oslo, Norway
 Resuscitation attempted in 1183; 418 in ACLS with IV
access vs 433 without IV access
 Survival to discharge: 10.5% vs 9.2% (p=.61);
w/favorable neuro outcome (9.8% vs 8.1%)
 ROSC w/hospital admission was 32% w/IV
access vs 21% without IV meds (p<0.001)
 Questions value of ALS drugs
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Medication Administration
 Early IO access recommended—can be used for all
drugs during resuscitation
 Always prefer central IV access over peripheral,
except fluid resuscitation often easier through secure
peripheral IV
 ET drug absorption is erratic; use 2-3 times IV dose
for most drugs, except 10 times for epinephrine
 Smaller epi doses may result in plasma concentrations
that favor ß2-adrenergic stimulation, which reduces
vascular resistance and coronary perfusion pressure
 Insufficient data to recommend ideal body mass vs.
weight-based dosing; latter recommended during
CPR
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Medications
 Calcium not recommended for pediatric cardiac
arrest except for documented hypocalcemia, CCB
toxicity, hyperMg, hyperkalemia
 Adenosine recommended as safe and potentially
effective for treatment and diagnosis in initial
management of undifferentiated regular
monomorphic wide-complex tachycardia.
 Use actual body weight or body length tape to
calculate doses. Do not exceed adult dose
 Epinephrine dose and indications unchanged—
more data against high-dose epinephrine.
Drug therapy in cardiac
arrest
 In children, epinephrine remains the drug of choice
 Initial dose of 0.01 mg/kg
 Data do not support subsequent high doses of epinephrine;
may be considered, but not recommended.
 Consider in sepsis, ß-blocker overdose, other conditions
characterized by poor catecholamine responsiveness
NEJM 2004; 350:1722-30
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High‐dose epinephrine vs. standard dose for in‐hospital pediatric cardiac arrest
Perondi M, et al. NEJM 2004; 350:1722-30
 n=68 (34 each)
70
 In-hospital, blinded RCT 60
 HDE rescue did not
improve ROSC (20/34
vs 21/34)
 HDE resulted in worse
24-hour survival
58
62
50
40
HDE
30
20
10
SDE
*
20.5
12
3
0
0
ROSC 24 HR D/C
1/34 HDE vs. 7/34 SDE survived >24 hours
33
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Medications
 Atropine: Not routinely recommended in PEA;
only for hemodynamically significant bradycardia
due to increased vagal tone or AV block
 Consider epinephrine or pacing
 Sodium bicarbonate: Not routinely recommended
during CPR. Use for hyperkalemia (but glucoseinsulin better) and TCA overdose
 GWTG analysis - use of NaHCO3 associated with
increased mortality – submitted for publication to
Circulation
Morley PT. Drugs during CPR. Curr Opinion Crit Care 2011; 17:214‐8
Calcium
 Long used in cardiac arrest—important for cardiac
contraction
 Extracellular concentration is 10,000 fold higher than
intracellular concentration!
 Increased intracellular Ca mediates final pathway for
cell death
 Calcium use was associated with increased mortality*
 Used in 45% of 1477 in-hospital arrests; use associated
with ICU location, prolonged arrest and use of other
ALS medications
 Indicated for hypocalcemia, CCB overdose,
hyperkalemia and hypermagnesemia
 Ca gluconate is as effective as Ca Chloride; gluconate
preferred for peripheral venous administration
*Srinivasin35 et al. Pediatrics 2008; 121:e1144-51
Vasopressin
 Other than anecdotal reports, there are no data on its
use in pediatric arrest
 NRCPR data reported that its use was associated with
increased mortality*
 Selection bias and only used in 4.9% of cases (64
cases), mostly PICU in large children’s hospitals
 Vasopressin may be useful in vasodilated,
catecholamine-refractory states (eg, sepsis,
occasionally after CPB)
 Optimal bolus dose is unknown – 40 IU used in
adults so 0.5 – 1 U/kg has been used in children
*Duncan JM, et al. Ped Crit Care Med 2009; 10:191
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Miscellaneous Medications
 Amiodarone is highly effective for both
ventricular and supraventricular arrhythmias
 Complex pharmacology with very long half-life
 Avoid if prolonged QT or giving other drugs that
prolong QT interval
 May cause severe hypotension with rapid IV admin
 Naloxone doses are different based on indication:
 Use 0.1 mg/kg (100 mcg/kg) for intentional opioid
overdose
 Use 0.001 – 0.005 mg/kg (1 – 5 mcg/kg) to antagonize
respiratory depression due to too much narcotic
 Etomidate not recommended if evidence of
shock
Pediatric Resuscitation
 Revised pediatric chain of survival
 New post-arrest care link
© 2010 American Heart Association. All rights reserved.
Post-resuscitation care
 Myocardial dysfunction is common after cardiac
arrest. Vasoactive agents may improve
hemodynamics, but drug selection must be tailored to
the patient because clinical response is variable.
 Some post-arrest patients develop a SIRS (sepsis-like)
clinical picture; others have cardiogenic shock
 Vasoactive therapy should be based on patient’s
hemodynamic state and desired goals
 But, don’t know best method of monitoring
cardiovascular function or the optimal hemodynamic
goals used to monitor and titrate therapy
 No specific MAP goal; may want afterload reduction to
improve cardiac output
39
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Post-resuscitation care
 Fluid may be required to compensate for altered
capillary permeability, reduced vascular tone and
SIRS response
 3 L of iced NS or RL tolerated in post-ROSC adults
 Like sepsis, may benefit from monitoring venous
oxygen saturation (central) if available
 Evaluate arterial – venous oxygen content difference
 Monitor lactate clearance
 Maintain adequate MAP; some data suggests
benefit from increased MAP early post arrest
 Consider ECHO to objectively assess cardiac fx
Post-resuscitation care
Postresuscitation Care – Bundle of Interventions
Do not routinely hyperventilate – impairs venous
return and may reduce cerebral blood flow
Avoid hyperthermia!
Monitor temperature and treat fever aggressively
Monitor glucose – attempt to maintain “normal”
glucose concentration







No data to support avoiding glucose in IV fluids
Tight glucose control associated with much higher risk
of significant hypoglycemia and increased ICU
mortality
Consider induced hypothermia (32oC to 34oC) for
patients comatose after resuscitation from cardiac
arrest.
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Post-resuscitation care
Postresuscitation Care – Bundle of Interventions
Bicarbonate for correction of acidosis – is it valuable?


Be sure ventilation is adequate

Monitor urine output, but beware of hyperglycemiainduced diuresis and high-output renal failure

At risk for seizures – may be subclinical, so have
low threshold for EEG, treatment


Prophylactic anticonvulsants?
Prognostication difficult immediately post arrest
and not reliable if patient receives therapeutic
hypothermia
Morrison LJ, et al. Strategies for improving survival after in‐hospital cardiac arrest in the United States: 2013 Consensus Recommendations. Circulation 2013; 127:1538
42
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Pediatric Advanced Life Support
 Ventilate with 100% Oxygen during CPR, but post-
ROSC: titrate oxygen to limit hyperoxemia. Adjust FIO2
to maintain sats >94% but <100 %
 Data from RCT’s support the use of therapeutic
hypothermia (32oC to 34oC) in at least select postarrest/resuscitation populations in newborns and
adults, but data lacking in children
 It is clear, however, that increased temperature should
be avoided – maintain normothermia
Oxygen vs. Room Air
 In non-neonate still
recommend 100%
oxygen during BLS &
ALS when available to
maximize CaO2 & DO2
 Following ROSC:
titrate FiO2 to achieve
SaO2 of ≥ 94% and
<100%.
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Oxygen vs. Room Air
 Oxygen is essential to cell function, BUT
 Reperfusion stimulates production of reactive oxygen
species and oxygen radicals result in tissue injury
 Limiting oxygen exposure during and after
resuscitation reduces the reperfusion injury
 Caveat: if hgb is 3 g%: CaO2 = 3* 1.34 + PaO2*.003;
if PaO2 is 90 torr CaO2 = 4.29 mL O2/100 mL blood.
 If increase the PaO2 to 500 torr, the dissolved oxygen
concentration increases to 1.5 mL and total oxygen
content increases to 5.52 mL/100 mL of blood,
representing a 29% increase.
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Summary
 Many resuscitation systems and communities have




documented improved survival from cardiac arrest when
high quality CPR is emphasized – push fast, push deep,
minimize interruptions and no leaning!
C-A-B sequence is a major change in training – requires
unlearing
New emphasis on use of continuous wave capnography
to monitor endotracheal tube position and quality of CPR
Epinephrine and amiodarone are only drugs with data
supporting their use, although epi is controversial
Victims require excellent post–cardiac arrest care by
organized, integrated teams.
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