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Pediatric & Neonatal Resuscitation

Pediatric & Neonatal Resuscitation. Dr. Edward Les. Outline. Case-based Illustration of basic PALS/NALS principles Emphasis on differences from adults What’s new in pediatric resuscitation ILCOR 2000 guidelines and beyond Pre-hospital care controversies

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Pediatric & Neonatal Resuscitation

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  1. Pediatric & Neonatal Resuscitation Dr. Edward Les

  2. Outline Case-based • Illustration of basic PALS/NALS principles • Emphasis on differences from adults • What’s new in pediatric resuscitation • ILCOR 2000 guidelines and beyond • Pre-hospital care controversies Pediatric trauma not covered – Sept 11

  3. Why do kids freak docs out? • Infrequently treat critically ill children • Emotional aspect of death/illness in child vs adult • Age/size related issues – how to remember what’s normal, what equipment/drugs to use, etc…… especially when the s#$@ is hitting the fan

  4. Simplify, simplify Most of us can’t drive, eat a sandwich, read the newspaper, and balance the chequebook at the same time…

  5. Reduce your cognitive load: • Make non-automatic behaviours automatic ones as much as possible • Know the essentials of what’s different about pediatric anatomy/physiology • Learn a few basic rules of thumb • Use resuscitation aids!! Luten, R. et al. Acad Emerg Med 2002; 9:840-847

  6. Black et al. Emerg Med 2002; 14:160-165 • Prospective comparison of six weight-estimation methods in 495 kids in ED • Broselow tape and DWEM most accurate • APLS method was the worst!

  7. 3 year old in father’s arms lethargy, decreased appetite today Dad noticed rash several hours ago on neck, now entire body covered P 150 R 32 BP 76/30 T 39.1 Sats 94% Toxic appearance, sleepy Airway patent, good BS CRT 5 seconds Petechial rash Case

  8. Heart rate norms

  9. Heart Rates in Children Infant 85 220 300 Normal Sinus Tachycardia Cute l’il Moritz SVT Child 60 180 200 Normal Sinus Tachycardia SVT

  10. Normal resting RR Newborn 30-60 Infant (1–6 months) 30-50 Infant (6-12 months) 24-46 1-4 yrs 20-30 4-6 yrs 20-25 6-12 yrs 16-20 >12 yrs 12-16 * >60 abnormal in all age groups

  11. Estimate of Minimum Systolic Blood Pressure Age Minimum systolic blood pressure (5th percentile) 0 to 1 month 60 mm Hg >1 month to 1 year 70 mm Hg 1 to 10 years of age 70 mm Hg + (2 x age in years) >10 years of age 90 mm Hg

  12. Hypotension: LATE! SUDDEN! Compensated vs decompensated shock

  13. Back to case... IV access? • Attempt IO immediately • Previously attempt PIV 90 seconds • Useful adjunct in ALL age groups • Previously < 6 years • All drugs, fluids OK; can draw bloodwork • Complications: #, compartment, infection

  14. McCarthy et al. Resuscitation 2003; 56:183-186 “Successful intraosseous infusion in the critically ill patient does not require a medullary cavity” Adult cadaveric specimens Successful infusion of methyl green in 5 of 8 case using the calcaneus and radial styloid

  15. ABC’S (S=Sugar) • Routine rapid assessment of blood sugar: delay in dx of hypoglycemia  irreversible CNS damage • 18/49 (18%) of nontrauma-related pediatric resusc cases: Low BG Losek, JD. Annals of Emergency Medicine 2000 35(1)

  16. sweets – how much? D10W 5-10 mL/kg D25W 2-4 mL/kg *Use D10W 2-4 ml/kg in newborns

  17. Case: 11 p.m. at ACH • 15 month boy carried in by Dad • Acute onset barky cough, noisy breathing • Airway patent, audible stridor at rest with nasal flaring and accessory muscle use; no drooling • P 175, BP 95/50, RR 42, sat 96% RA

  18. Case (cont) • Gets racemic epi, 02, dex • Initial good response • 1 hour later: rebound resp distress with significant stridor • P 175, R28, sat 86% on 2 LPM by NC, becomes somnolent despite repeated racemic and BVM

  19. RSI for kids • Preoxygenation: may need PPV with Sellick maneuver (sedate first) • Basal oxygen use per kg 2x adults: shorter “safe apnea” interval before desaturation • Premed: Atropine 20 mcg/kg (minimum 100 mcg) • < 1 y.o. • 1-5 y.o. receiving sux • Adolescents receiving 2nd dose sux

  20. RSI for kids • Premed: defasciculation recommended with sux when > 5 y.o. • Paralytic: Tendency to avoid sux; certainly avoid 2nd dose: infants/children exquisitely sensitive  intractable brady/arrest • Rocuronium good alternative

  21. ETT size? cuffed? depth of insertion? Broselow – best!! (16 + age in years) 4 Uncuffed < 8 years old (exceptions) Depth of insertion (cm): tube ID (mm) x 3 or age (yrs)/2 + 12 In this15-month-oldwith croup…

  22. (16 + age in years) 4 Broselow overestimated tube size in > 50% Correct size in 41% correct size in 55% tendency to underestimate tube size Hofer et al. Br J Anaesth 2002; 88:283-285

  23. Anatomical airway issues in kids • big tongue, soft tissue  obstruction • narrowest at subglottis, soft trachea  no cuff • anterior/cephalad larynx  difficult visualization • short trachea  R mainstem intubation • nose breathers < 4 mos • big occiput  neck flexion • big floppy epiglottis  straight blade

  24. failed intubation • BMV with Sellick • LMA an option • No cricothyroidotomy under 8 years • in a pinch: Needle cric

  25. Case 22 year old female brought to ED by ambulance c/o severe abdo pain/bleeding @ 34 wks GA • As moved from ambulance – membranes rupture, infant delivers through bloody, mec-stained amniotic fluid • Infant is cyanotic and flaccid, no spont resps; appearance consistent with 34 wks GA What now?

  26. Save the baby • Call for help - NICU • Warm, dry, position, suction (+/- mec), stimulate, free-flow O2 • BVM – when? What about the meconium? • Chest compressions – when, how often? • Intubate – tube size? • Meds – which? Dosages? • Fluids – how much, what, where?

  27. O2 – 21% or 100%? • Saugstad et al. Resuscitation of newborn infants with 21% or 100% oxygen: follow-up at 18-24 months. Pediatrics 2003; 112:296-300 • Saugstad et al. Resuscitation of asphyxiated newborn infants with room air or oxygen: an international controlled trial: the Resair 2 study. Pediatrics 1998; 102:1 • Vento et al. Resuscitation with room air instead of 100% oxygen prevents oxidative stress in moderately asphyxiated term neonates. Pediatrics 2001; 107: 642-647 • Ramji et al. Resuscitation of asphyxic newborn infants with room air or 100% oxygen. Pediatr Res 1993; 34:809-812 • Lundstrom et al. Oxygen at birth and prolonged cerebral vasoconstriction in preterm infants. Arch Dis Child 1995; 73:F81-F86 • Vento et al. Six years of experience with the use of room air for the resuscitation of asphyxiated newly born term infants. Biol Neonate 2001; 79:261-267

  28. O2 – 21% vs 100% • No differences in outcomes • ? Some evidence of oxygen toxicity • Studies plagued with problems Bottom line – jury’s still out - no change to protocols yet

  29. Most newborns save themselves

  30. neonatal/preemie CPR • Ventilation 40-60 minute • Compression rate 100/minute • Together: • 120 events per minute in 3:1 rhythm = 90 compressions/30 breaths/minute

  31. Preemies

  32. Meconium 10-20% of all deliveries Suction nose and mouth when head delivered • If vigorous : routine care • If depressed (poor resp effort, flaccid, HR < 100)  direct visualization of glottis on warmer and suction below cords** **before drying/stimulation

  33. > 100 mm HG suction; repeat passes if necessary and if have time • OG to empty stomach of green muck

  34. Newborn – resus meds Epinephrine: 0.1 to 0.3 mL/kg 1:10,000 IV or intratracheal *never use 1:1000 epi* Naloxone: 0.1 mg/kg IM/IV/SC/ETT if narcotics during delivery * do not use if mom drug user Sugar: D10W 2 ml/kg IV

  35. Newborn – volume expansion • Use umbilical vein • 3.5 or 5 Fr • Depth 1 to 4 cm (good blood return) • 10 ml/kg/bolus NS

  36. Case • Frantic mom runs up to triage with her 8 month old son; her 3 year old gave him a piece of popcorn in the car about 5 minutes ago. He has been choking and coughing ever since. Mom tried to retrieve it with her fingers but couldn’t grab it. Now he’s visibly cyanotic, has obvious stridor, flailing his arms…. • What to do first?

  37. Foreign body airway obstruction No abdominal thrusts under 1 year of age (risk of organ damage) • Alternate 5 back blows with 5 chest thrusts until relief of obstruction or unresponsive

  38. Case You’re knocking a soccer ball around with some little neighbourhood kids at the park, when a little six year old boy suddenly keels over while chasing the ball. You run over and find him unresponsive, not breathing, no pulse.

  39. Case (cont) Do you: a) provide CPR , then call 911 or b) call 911, then provide CPR

  40. Chain of Survival > 8 years • Phone first, then provide CPR Exception: unresponsiveness with respiratory compromise (submersion, trauma, drug overdose) “Phone FIRST” vs “Phone FAST” < 8 years • CPR first, then phone fast Exception: apparent sudden cardiac collapse

  41. Pediatric CPA • Much less likely primary cardiac • Generally… • Progression from hypoxia and hypercarbia (respiratory failure) OR shock  respiratory arrest and bradycardia  asystolic cardiac arrest • Therefore ventilation (CPR) priority over defib (vs adults) • Recognize early respiratory failure and shock: “Keep the pulse”

  42. Generally, of survivors… Airway intervention saves 90% IV access saves 9% Drugs save 1%

  43. Out-of-hospital SIDS Trauma (most common > 6 months) Submersion Sepsis Cardiac diagnosis Pulmonary disease In-hospital Sepsis Respiratory failure Drug toxicity Metabolic disorders Arrhythmias Etiologies

  44. Pediatric CPA Collective review of 41 published studies by Young and Seidel (3,094 patients) Ann Emerg Med 1999. 33(195-205) • small sample sizes • poor standardization • vague definitions 50% < 1 year Out of hospital arrest witnessed in 31% • Bystander CPR in 30% of these Initial rhythm: bradysystole 73% VF/VT 10%

  45. Engdahl et al. Resuscitation 2003; 58:131-138 20 years: 98 cases of pediatric CPA 42 % less than 1 year of age Witnessed arrest 34 % Initial rhythm: asystole 65% v.fib 8% PEA 19%

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