PALS: New and Old

1. PALS:New and Old David Chaulk PEM Fellow January, 22, 2004

2. Outline • A&B then C • Illustrative Case • Back to Basics • Current Guidelines • Hot Topics • Pre Hospital Care • Changes in the 2000 Guidelines • When to stop

3. A&B….Case • A 16 month boy presents to your ED and is noted to be seizing. From history it is not clear when the seizure started. Possibly an hour ago. You move him into the Resus room. • He continues to seize. His vitals: HR 180, BP 105/65, RR 24 T 376 (T)

4. A&B…Case • You give ativan 0.1mg/kg x2. Clinically he is not seizing but HR still high and GCS 3. • You load with phenytoin 20 mg/kg • No change. • Decision: CT and intubate (failure to protect airway)

5. A&B…Case Questions • What is the best method of estimating tube size? • What is the evidence/guidelines for LMA use? • How do we know that the tube is in place?

6. A&B… Anatomic Differences • Relatively large tongue • Funnel shaped trachea (subglottic narrowing) • Larynx located anteriorly • Short trachea (RMS intubation) • Big head (large occiput causes flexion) • Floppy epiglottis

7. A&B…Intubation

8. A&B…Intubation • Tube Size • Methods • (age/4) + 4 • Broselow • Hofer, et al., 2002 • Formula • overestimated tube size in >50% • Correct 41% • Broselow • Tendency to underestimate • Correct 55%

9. A&B…Intubation • Cuffed vs. Uncuffed • Recommendation is less than 8 years, uncuffed

10. A&B…Which Blade? • No clearly defined guidelines • Younger child = floppier epiglottis • Use a straight blade and pick it up • Older child = more like an adult • Curved blade and into vallecula

11. That’s some of the basics…what’s new and controversial?

12. A&B…The LMA • Guideline Change The LMA is a viable and effective alternative…for establishing the airway in children during resuscitation Zideman, et al, Ann Emerg Med, Apr 2001

13. A&B…The LMA • Clayton, et al., 2001 • Airway management by OR nurses • Compared BMV and COPA (cuffed oropharyngeal airway) in 40 anesthetized patients • 32/40 (80%) successfully ventilated with BMV • 38/40 (95%) success with COPA

14. A&B…The LMA • Clayton, et al., 2001 • Secondary Outcomes • Mean expiratory volume better with LMA • Leak was better with BMV • ?relevance if volumes are better with LMA • Airway Trauma • BMV 0/40 (0%) • COPA 4/40 (10%) • Trauma described as blood tinged saliva upon removal of device

15. A&B…The LMA • Important Notes • No LMA studies in PALS situations • Unskilled (but trained) operators more successful with LMA then BMV • LMAs may be easily dislodged • Risk of aspiration lower than with BMV but still a risk • BMV 12%, LMA 3% • Two studies, similar results Chibber et al., 1997 and Tobias et al., 1997

16. A&B…Esophageal? • Previous Guideline (1992) If the tube is in proper position, the chest should rise symmetrically during positive-pressure ventilation, and breath sounds should be easily auscultated over both lung fields and especially in the axillary areas. Breath sounds should be absent over the upper abdomen.

17. A&B…Esophageal? • Proposed Change A device should be used to confirm the position of the tracheal tube after each intubation in all settings (eg, outside-of- hospital setting, the emergency department, and in the intensive care unit). Zideman, et al, Ann Emerg Med, Apr 2001

18. A&B…Esophageal? • Colorimetric Devices • Prospective study Bhende et al., 1992 • 151 intubations , 137 children • 128/151 had perfusing rhythms • Colour change PPV 100% • No colour change NPV 100% (n=4)

19. A&B…Esophageal? • 23/151 children were in cardiac arrest • No colour change NPV 84% 11/13 • Bhende et al., 1995 • 40 children in cardiac arrest that were intubated • Colour change PPV 100% • No colour change NPV 60% (tube was tracheal 6/15 with no colour change)

20. A&B…Esophageal? • Bhende et al., 2002 • 39 intubations in 38 patients • Evaluated a newer device (Capno-Flo) • 100% sensitive and specific (no false +/-) • Not useful for continuous monitoring • Puntervoll et al., 2002 • Intubated 14 patients tracheal and esophageal • Colorimetric accurate 100% • 5 patients instilled CO2 into esophagus…colorimeter showed CO2 ?!

21. A&B…Esophageal? • Colorimetric Device • Very accurate if colour change present • Questionable if no colour change • Questionable in cardiac arrest • Recommend 6 ventilations prior to decision-making

22. A&B…Esophageal? • Esophageal Detector Device (Briefly) • A syringe, easily w/d tracheal, not esophageal • Morton (’89), 5-10 y and Wee (’91) 1-10 y • NPV and PPV 100% (Morton n=20, Wee n=100) • Haynes and Morton (1991) 2w-9m, n=20 • 25% failure rate, 3 false (+), 2 false (-) • PPV 73%, NPV 78% • Insufficient data to recommend EDD

23. A&B…Esophageal?This little Piggy went to market… • 30 blinded volunteers assessing a 32 kg intubated Pig • EDD and CO2 NPV and PPV 100% • Clinical missed 3 esophageal tubes • Secondary Outomes • EDD 13.8 s • CO2 31.5 s • Clinical 39 s

24. A&B…Esophageal?The Bottom Line • Colorimetric changes are specific after 6 ventilations • A positive colour change indicates correct placement of the tube

25. A&B…Esophageal?The Bottom Line • No colour change is not helpful • Not a reliable test in cardiac arrest • In these cases, must rely on clinical evaluation and direct laryngoscopy that the tube is in position

26. Circulation & Cardiac Output

27. C…Case • The mother of an 11 yo boy runs into the hospital with her limp child (he has a complicated PMHx). • The nurse moves them to the Resus room and calls you stat. • On history, he has had a brain tumour and has had a stroke in the recent past. He suddenly collapsed.

28. C…Case • On examination he is making no respiratory effort, you do not detect a pulse and there is asystole on the monitor. His pupils are fixed and dilated.

29. C…Questions • What is the best way to check cardiac activity in a potentially pulseless child? • Is there a difference in location in terms of cardiac compressions? • What is the most efficient method for attaining vascular access?

30. C…Questions • Epinephrine. Standard or High Dose? • What other drugs should be used? • Bicarb? • Vasopressin? • Not related to this case but…What are the new guidelines for amiodarone?

31. C…Cardiac Activity • New BLS guidelines (2000) state that the layperson should start CPR immediately if there are no signs of life because checking the pulse is inaccurate and time consuming • What is the best method to assess cardiac output?

32. C…Cardiac Activity • Ingawa et al., 2003 • Compared 5 techniques for assessing pulse • 28 OR nurses assessing 13 infants (with pulse)

33. C…Chest Compressions • How should compressions be performed in infants? • PALS guidelines • Two rescuers should use two thumb technique • Lone rescuer should use two finger technique • Whitelaw et al., 2000 • 209 participants compressing an infant model

34. C…Chest Compressions • Whitelaw et al., 2000 • 209 participants compressing an infant model • 71% failed to give adequate compressions with either technique • 19.1% were adequate with thumbs • 18.1% were adequate with fingers (not statistically different) • Finger group had more shallow compressions than thumb group (19.1% vs 7.2%)

35. C…Chest Compressions • Finger Postion (PALS Recommendations) • Infants: 1 cm below intermammary line • This is controversial • Clements & McGowan, 1999 • Studied 30 adults and 30 children • Measured the intermammary line distance to the xiphiod, mean distance 2.3 cm (range 1.0-3.5cm) • Measured the distance the adults fingers would span using the recommended method • Mean distance 4.4cm (range 4.0-5.5cm)

36. C…Chest Compressions • Finger Postion (PALS Recommendations) • Children 1-8 years:heel of hand between xiphoid and intermammary line • Children > 8 same as adults

37. C…Prone Positioning • Topic being looked at in the adult literature • Mostly case reports • 1 recent study • Not mentioned in PALS • Only 1 pediatric case report in the literature

38. C…Prone Positioning • Theory: • Easier to learn and perform • Maintains airway • Minimal aspiration risk • Provides compressions and ventilatory assists without the need to switch • Increased likelihood of bystander intervention with elimination of need for MTM • Less likely to injury the victim if wrong diagnosis • Stewart, 2002

39. C…Prone Positioning • Mazer et al., 2003 • Cross over study of 6 patients that failed 30 mins of standard CPR • Given 15 (additional) mins of standard then 15 mins of prone CPR • No patients had spontaneous return of circulation

40. C…Prone Positioning Results * Not significantly different

41. C…Prone Positioning • 1 pediatric case report • 6 month old achondroplastic child in the OR • CPA • Successful Prone Position Resuscitation

42. C…Vascular Access • Previous Guideline: • In children, 6 years of age and younger , intraosseous vascular access should be established if reliable venous access cannot be achieved within three attempts or 90 seconds, whichever comes first. • JAMA, 1992

43. C…Vascular Access • New Guideline • Intraosseous access should be established in any patient when intravenous access cannot be rapidly achieved in the presence of cardiac arrest or decompensated shock. • Atkins et al., 2001 • A practical approach is to pursue IO and peripheral or central access simulatneously • PALS Provider Manual, 2002

44. C…Drugs • Standard vs. High Dose Epinephrine • History • Several animal studies in late 80’s suggested high dose epi (0.1mg/kg) was more effective than standard dose (0.01mg/kg) • Small Pediatric study with similar results • 1992 PALS Guidelines recommended first dose standard and second dose high

45. C…Drugs • High vs. Standard dose Epinephrine • Since then multiple, large adult studies have refuted this • Pediatric retrospective study of 51 patients and 58 CPA’s • 21 patients received HDE in 24 arrests • 30 patients received SDE in 34 arrests

46. C…Drugs Results *significantly different

47. C…Drugs • Current Epinephrine Guidelines • Standard dose epinephrine for initial and subsequent • The PALS provider may consider high dose epinephrine by intravascular route • PALS Provider Manual

48. C…Drugs • What is the role of Vasopressin? • No indication in the current guidelines • A hot topic both in pediatric and adult critical care and resuscitation • Little evidence (for or against) in pediatrics

49. C…Drugs • Vasopressin • Voelckel compared Epi and AVP in piglet pediatric models (2000 and 2002) • 2000, looked at asphyxia • Epi not different than epi and AVP, superior to AVP alone • 2003, looked prolonged VF • Epi and AVP superior to epi or AVP alone • Outcome in both was LV blood flow

50. C…Drugs • Mann et al., 2002 • Retrospective analysis of 6 arrests in 4 patients • Given as “intervention of last resort” • ROSC > 60 mins in 4 of 6 • 2/4 patients survived > 24 h • One surivived to discharge • One family withdrew care • Vasopressin not recommended at this time (class indeterminate)