E N D
1. 2007 Stollery PICU Conference Pediatric Resuscitation:2005 HSFC & AHA PALS Guidelines Allan de Caen MD, FRCP(C)
PICU, Stollery Childrens Hospital
University of Alberta
Edmonton, Canada
2. 2007 Stollery PICU Conference Objectives Major PALS Guidelines changes for 2006
Pediatric cardiopulmonary arrest prognostication
CPR technique and the role of ventilation
vasopressor/ catecholamine use
ETT and IO drug delivery
defibrillation
post-resuscitation temperature management
cuffed vs. uncuffed ETT
3. 2007 Stollery PICU Conference
4. 2007 Stollery PICU Conference EMS patches in to the ED giving a heads-up that they are 5 minutes out with a 3 week old child with presumed sepsis that is in cardiac arrest in their ambulance.
What resuscitation algorhythm do you follow: neonate or child?
5. 2007 Stollery PICU Conference
NRP
Newlyborn: newborn until d/c from nursery
Infant: d/c from nursery to 1 yo
Child
Layperson: 1 yo to 8 yo (AED-related defn)
Health care provider: 1 yo to S/S of puberty
ACLS for the teenager in crisis?
6. 2007 Stollery PICU Conference ALS care has been provided for 15 minutes.
How long should you continue resuscitation for?
7. 2007 Stollery PICU Conference Outcome from Cardiopulmonary Arrest (CPA) in Children is poor. Out of hospital CPA
Survival to hospital D/C: 2-15%
Sirbaugh 1999, Young 2004, Herlitz 2005, Lopez-Herce 2005
? 6 month/ 1 year survival; CNS status?
In-hospital CPA
24 hr survival: 33-37%
1 yr survival: 10-20%
72-83% still at pre-CPA Neuro baseline
Torres 1997, Suominem 2000, Reis 2002
8. 2007 Stollery PICU Conference Why is outcome of pediatric cardiac arrest so poor? Minority of pre-hospital pediatric cardiac arrests have CPR provided by bystanders on scene (significant delay in time to CPR)
39% (Mogayzel, 1995)
26% (Sirbaugh, 1999)
31% (Young, 2004)
68 % (Herlitz, 2005)
9. 2007 Stollery PICU Conference Pediatric CPA: Prognostication Previously used markers for limiting duration of resuscitation (ie. ~20 minutes or 2 rounds of epinephrine) may now be inaccurate, especially when CPAs occur in ECLS centres
10. 2007 Stollery PICU Conference What compression: ventilation ratio should be used for this 3 week old infant, and why?
3:1
5:1
15:2
30:2
11. 2007 Stollery PICU Conference What does CPR do? The critical effect of chest compressions is the generation of coronary artery perfusion pressure (CAPP)
the higher the coronary perfusion pressures, the better the survival
Halperin 1986, Feneley 1988, Paradis 1990
12. 2007 Stollery PICU Conference Ventilation impedes effective chest compressions 30% of is time in a single rescuer 5:1 C/V ratio is lost in transferring between compressions and ventilations
Whyte and Wyllie, Resuscitation, 1999
15:2 ratios limit the maximum number of compressions provided by single rescuers to 45 per minute, due to the 16 second pause in compressions needed to deliver 2 breaths (effectively?)
Chamberlain et al, Resuscitation, 2002
13. 2007 Stollery PICU Conference Ventilation impedes effective chest compressions
14. 2007 Stollery PICU Conference ABGs after 7 min of CPR for VF-CPA
15. 2007 Stollery PICU Conference VF-CPA and CNS Outcome(12 min of CPR after 3 min of VF)
16. 2007 Stollery PICU Conference Asphyxial-CPA and C:V ratios (after 7 min of CPR following asphyxial CPA)
17. 2007 Stollery PICU Conference Asphyxial-CPA and C:V ratios
18. 2007 Stollery PICU Conference Science Summary More CC / min are associated with greater coronary perfusion pressures and greater survival in animal models
Ventilation is relatively unimportant in the first 10 minutes after collapse from VF
Early ventilation is necessary when resuscitating asphyxial cardiac arrest, but a 15:2 ratio may be adequate
Withholding chest compressions for 20 sec can reduce the probability of resuscitation from 50% to 8%
Eftestol, Circulation, 2002
19. 2007 Stollery PICU Conference Pediatric BLS 2005 For unwitnessed cardiac arrest
Child: phone fast
2 minutes CPR, then leave to call 911/ retrieve AED
Adult:
Lay rescuer: call first (> 8yo)
HCP: call fast if suspected asphyxial arrest (eg. drowning/ injury) (post-pubertal)
For sudden witnessed collapse
Child and adult: phone first
apply AED/ defibrillator as soon as available
Wik, JAMA, 2003
20. 2007 Stollery PICU Conference CPR: Guidelines 2005 Infants (older than the newlyborn) and children (to puberty) will be resuscitated with C:V ratios of:
30:2 single rescuer
(generally pre-hospital lay rescuer)
15:2 two rescuer
(health care provider)
Children with signs of puberty will be resuscitated with C:V ratio of 30:2, both by lay rescuer and health care provider, in-hospital and out of hospital
The universal pre-hospital algorhythm will hopefully lead to more patients actually getting pre-hospital CPR (easier to teach, learn and perform)
21. 2007 Stollery PICU Conference Take-away messages
CPR
Harder
Faster
Dont lean on the chest
Minimize interruptions
(pulse/ rhythm checks/ time for intubation or ventilation)
22. 2007 Stollery PICU Conference EMS has been unable to intubate the infant.
Is there a down-side to even taking the time to successfully intubate this infant?
What kind of ETT should be used; cuffed vs uncuffed, or does it matter?
23. 2007 Stollery PICU Conference How effectively are we BVM ventilating anyways? (pediatric mannequin study)
24. 2007 Stollery PICU Conference Time to place a secured airway during CPA
25. 2007 Stollery PICU Conference Cuffed vs. Uncuffed ETT in Children AGAINST Cuffed tubes
Cuff unnecessary, (normal subglottic narrowing)
Subglottic mucosal injury potentially resulting in tracheal stenosis (pressure injury if unmonitored).
The correct placement of the tube is more difficult when using a cuffed tube
Use of a cuffed tube requires a slightly smaller tube for age (0.5-1.0mm), which increases airway resistance and hence increases spontaneous breathing effort. FOR the use of cuffed tubes
A glottic airleak may complicate ventilator management (ie. if poor lung compliance/ high airway resistance (**).
Reduced risk of aspiration.
More accurate measurement of end-tidal CO2
26. 2007 Stollery PICU Conference Cuffed vs. Uncuffed ETT in Children Newth, J Peds, 2004
1 yr prospective study investigating incidence of airway complications after extubation of children (< 5yo) with cuffed or uncuffed ETTs (PICU)
No significant difference in airway complications
27. 2007 Stollery PICU Conference Guidelines 2005 and the use of cuffed ETTs in pediatrics In the in-hospital setting, a cuffed tracheal tube is as safe as an uncuffed tube for infants (except the newlyborn) and children (no difference in airway complications)
Newth, J Peds, 2004
In certain circumstances (eg, poor lung compliance, high airway resistance, or a large glottic air leak) a cuffed tube may be preferable, provided that attention is paid to tracheal tube size, position, and cuff inflation pressure
28. 2007 Stollery PICU Conference PALS Airway Guidelines 2005 LMAs are acceptable when used by experienced providers
While EtC02 monitoring is more commonly used, esophageal detector devices can be used to confirm endotracheal tube position in children >20 Kg who have a perfusing rhythm
Cuffed ETT size calculation
Cuffed ETT size = (Age (years/ 4) + 3
29. 2007 Stollery PICU Conference The RT asks you how quickly you would like to ventilate this patient?
You pause and consider the issues
Does excessive assisted ventilation worsen outcome of CPA victims?
What is excessive ventilation?
30. 2007 Stollery PICU Conference CPR/ ventilation and the secured airway Adults in pre-hospital CPA were ventilated by paramedics at a rate of 37+/- 4 bpm
Aufderheide et al, Circulation, 2004
Adults (in-patient) having a CPA are frequently hyperventilated during resuscitation
< 10 bpm 7.3%
> 20 bpm 60.9%
Abella BS, JAMA, 2005
Children being hand-ventilated appear to be to over-ventilated more than half (~62%) of the time
Tobias et al, Ped Emerg Care, 1996
31. 2007 Stollery PICU Conference
32. 2007 Stollery PICU Conference Does hyperventilation worsen outcome in the non-arrested shocky patient?
33. 2007 Stollery PICU Conference How much should we ventilate critically ill children in 2005? Using normal respiratory rates is probably over-ventilating when pulmonary blood flow is only a fraction of normal (arrested or shocky patient)
Guidelines 2005
If patient in cardiac arrest
Ventilate using 15:2 C:V ratio
once advanced airway in place, RR 8-10 bpm regardless of age), unsynchronized with CC
if patient has a pulse
RR 12-20 bpm
Take a deep breath, take your own pulse, and then ventilate slowly (it will still probably be too fast!!)
34. 2007 Stollery PICU Conference While assessing the infant, you note that he is pulseless.
After initiating CPR, you consider the issue of what drug to give.
Vasopressin?
Epinephrine?
Atropine?
By what route and how much should you deliver?
35. 2007 Stollery PICU Conference Epinephrine and Pediatric CPA While animal studies have shown that epinephrine increases coronary and cerebral blood flow during resuscitation, no human clinical evidence has demonstrated that epinephrine actually alters the long-term outcome (hospital admission, hospital d/c, neurological outcome) of pediatric or adult CPA
Young, 2004
49% of pediatric CPA survivors responded to CPR alone, and did not require epinephrine
36. 2007 Stollery PICU Conference High Dose Epinephrine: Are we doing harm? Worsened post-resuscitation myocardial function
Increased afterload
Increased myocardial metabolic work
Post-resuscitation myocardial failure/ death
Pro-dysrhythmic state
Worsened cerebral acidosis associated with high-dose epinephrine (uncoupling of oxidative phosphorylation):
worsening neurological outcome?
37. 2007 Stollery PICU Conference Pediatric epinephrine dosing: understanding the literature Limited number of human studies into HDE (n = 4)
Non-standardized patient groups
In-patient vs. pre-hospital
Disease states
Monitoring/ time to CPR, ALS
Small study numbers
Challenges in study design
retrospective (un-randomized) vs. uncontrolled
Failure to match for presenting rhythms
Inconsistent definition of dosing
HDE/ SDE = same dose via ETT or IV?
Poorly defined doses for HDE / SDE
Inconsistent entry timing to HDE
38. 2007 Stollery PICU Conference
39. 2007 Stollery PICU Conference
40. 2007 Stollery PICU Conference Vasopressors and Pediatric CPA: Guidelines 2005 Use epinephrine 0.01 mg/ kg/ dose, with no escalation to high dose epinephrine
The pediatric experience with vasopressin for CPA is limited to 1 small case series, 1 case report and some animal data
There is insignificant evidence to support/ refute the use of vasopressin for pediatric CPA
41. 2007 Stollery PICU Conference Drug delivery: Intraosseous (IO) Good literature to show that IO is placed faster and with greater success than peripheral IV access in severely dehydrated children
Studies of animals resuscitated from cardiac arrest have shown that whether drugs are delivered via peripheral intravenous, central line (IVC) or tibial IO, plasma epinephrine levels and physiological changes are equivalent
Andropoulos, J Peds, 1990, Orlowski, Am J DIs Child, 1990
42. 2007 Stollery PICU Conference ETT Drug Delivery: Challenges Multiple animal and human studies document erratic/ inconsistent absorption of LEAN drugs
ETT dosing of some drugs may be associated with side effects as demonstrated in animal models
B-mediated receptor effects (ie. reduced diastolic pressure and coronary artery perfusion) with low doses (0.01-0.02mg/ kg; ie. adult and neonatal guidelines) of ETT epinephrine
Efrati, Resuscitation, 2003
Depot effects with prolonged hypertension with ETT epinephrine
Mielke, Resuscitation, 2001
43. 2007 Stollery PICU Conference Guidelines 2005: IO vs ETT Better absorption and drug effect with IO compared to ETT drug delivery
Increasing availability of IO devices that are appropriate for all ages, neonates (Ellemunter, Arch Dis Child Fet, 1999) to adults (Iserson, J Emerg Med, 1989; MacNab, PreHosp Emerg Care, 2000) (eg. B.I.G., FAST device)
Reduced emphasis on the use of ETT medications (and increased role for IO drug delivery) when traditional venous access unavailable
44. 2007 Stollery PICU Conference
45. 2007 Stollery PICU Conference After giving a dose of epinephrine, the rhythm changes and the patient appears to be in ventricular fibrillation.
The nurse hands you one of their new biphasic defibrillators.
How much electricity do you give?
When should you defibrillate? (now or delay?)
When should you check for pulse/ rhythm changes?
46. 2007 Stollery PICU Conference Defibrillation: Whats new?
47. 2007 Stollery PICU Conference Biphasic Defibrillation Adult data (human and animal)
biphasic defibrillation is as successful in electrical conversion and potentially less injurious than monophasic waveform
no ROSC benefit (human)
Pediatric animal data
Biphasic defibrillation is as successful in electrical conversion and is less injurious to the myocardium than monophasic waveforms
Biphasic waveforms provide a survival advantage compared to monophasic waveforms in animals
no peds human data: extrapolation!!
Clark, Resuscitation, 2001, Berg, Circulation, 2004
48. 2007 Stollery PICU Conference Defibrillation Principles (new for 2005) Time to defibrillation is the most important factor impacting outcome for short (<5 min) CPA
in adults (and likely children) with a >5 min CPA, defibrillation is more likely to be successful after a period (2 minutes) of effective chest compressions
Wik, JAMA, 2003
Single, not multiple shocks, will be used due to the higher electrical conversion rate with biphasic waveforms, and the shorter period of time without CPR
49. 2007 Stollery PICU Conference Rhythm after first defibrillation (Biphasic) adultsadults
50. 2007 Stollery PICU Conference Defibrillation Principles (new for 2005) <5% of defibrillation shocks convert the patient immediately into a perfusing rhythm (pulse-present)
Do not do a pulse check immediately following defibrillation!
2 min CPR (ie. Chest compressions) post-defibrillation is appropriate before the next pulse check
If a second defibrillation is required, epinephrine should be given at time of 2nd shock (not delaying defibrillation)
Eilevstjonn, Resuscitaiton, 2005
On-going CC will not lead to VF recurrence in a patient with spontaneous circulation
51. 2007 Stollery PICU Conference
52. 2007 Stollery PICU Conference
53. 2007 Stollery PICU Conference PALS Changes in Defibrillation 2005 Infants and children needing defibrillation should receive first doses of 2J/ kg (either monophasic or biphasic), with escalation to 4 J/ kg for any further shocks delivered
Time to defibrillation is critical for CPA times< 5 min; high quality CPR is critical for reviving longer duration CPAs (2 min CPR ?pre-defib?)
Single shocks, immediately followed by 2 minutes CPR (delayed pulse or rhythm checks) are the new standard
no CPR interruption for drug delivery!!
54. 2007 Stollery PICU Conference The nurse gives you a new set of vitals after successful defibrillation
HR 190 BPs80 IMV 20 T 39C
One of your colleagues suggests that the patient should be cooled for neuro-protection.
You scratch your head and think to yourself
Where did this come from?
55. 2007 Stollery PICU Conference Hyperthermia and Outcome after CPA Fever is associated with worse neurological outcome in multiple studies investigating animals and humans (adults) after CPA (epiphenomenon vs. cause?)
Fever is commonly observed after CPA in children
Hickey, Pediatrics, 2000
Fever control in animals studied after cardiac arrest has been shown to improve neurological outcome
No high level evidence in humans
56. 2007 Stollery PICU Conference Hypothermia: Mechanisms of Protection There is ample experimental data supportive of hypothermic neuroprotection across a range of species (primate, dog, cat, rodent) and injury models (stroke, trauma, global brain ischemia)
Reduced cerebral / whole body metabolic rate
Direct anti-inflammatory actions
Deng Stroke 2003
???
57. 2007 Stollery PICU Conference Therapeutic Hypothermia:What does the animal literature tell us? Mild hypothermia (32-34 C) is adequate for neuro-protection in most scenarios
Early initiation is more effective than delayed initiation
Short duration (<12 h) vs 12-36 h is more likely to delay rather than prevent the evolution of injury.
58. 2007 Stollery PICU Conference Hypothermia post-VF (OOH) CPA in Adults Note: victims of non-VF CPA (ie. asphyxial CPA, commonly seen in children) were excluded from the trials
59. 2007 Stollery PICU Conference Hypothermia after Neonatal HIE Gluckman, Lancet, 2005
Multi-centre RCT: cooling of moderate to severely asphyxiated term neonates to 34-35C(r) within 6 hrs of birth for 72 hrs
No overall survival/ neuro-outcome benefit (post-hoc subgrp benefit?)
Eicher, Pediatr Neurol, 2005
Small pilot multi-centre RCT: cooling of moderate to severely asphyxiated term neonates (clinically defined; not EEG-graded) to 33C(rect) within 6 hrs of birth for 48 hrs
Survival and neuro-outcome benefit to hypothermia
Shankaran, NEJM, 2005
Multi-centre RCT: cooling of moderate to severely asphyxiated term neonates to 33.5C(eso) within 6 hrs of birth for 72 hrs
Significant survival and neuro-outcome benefit to hypothermia
60. 2007 Stollery PICU Conference Hypothermia: A down side ? Increased incidence of sepsis and pneumonia
Clemmer et al, Crit Care Med, 1992
Bohn, Crit Care Med, 1986
Increased incidence of coagulopathy
Rohrer et al, Crit Care Med. 1992
Increased incidence of dysrhythmias
Fuhrman, Pediatric Critical Care 1992
Risk factor for morbidity/ mortality for:
Trauma victims
Brun-Buisson JAMA. 1995
Critically ill neonates
Racine et al, Helv Paediatr Acta. 1982
All much less common with short periods of moderate hypothermia (32-34C)
61. 2007 Stollery PICU Conference Post-resuscitation hypothermia and Guidelines 2005 Consider cooling pediatric patients who remain comatose after resuscitation to a temperature of 32-34C for 12 to 24 hours because it may aid brain recovery
62. 2007 Stollery PICU Conference Induced Hypothermia after Pediatric CPA:What we do not know How quickly to warm?
How soon/ late can we warm after injury?
How cool do we need to warm to?
How long should cooling continue for?
How quickly should we rewarm, and to what temperature?
63. 2007 Stollery PICU Conference Questions?
64. 2007 Stollery PICU Conference
65. 2007 Stollery PICU Conference
66. 2007 Stollery PICU Conference
67. 2007 Stollery PICU Conference
68. 2007 Stollery PICU Conference
69. 2007 Stollery PICU Conference
70. 2007 Stollery PICU Conference
71. 2007 Stollery PICU Conference
72. 2007 Stollery PICU Conference
73. 2007 Stollery PICU Conference
74. 2007 Stollery PICU Conference NRCPR Pediatric CA data (n=880)
75. 2007 Stollery PICU Conference NRCPR Pediatric CA data (n=880)
76. 2007 Stollery PICU Conference Pediatric CPA (PICU)
77. 2007 Stollery PICU Conference How Well Did We Follow The 2000 Guidelines?
78. 2007 Stollery PICU Conference