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Rationale for the Current Paediatric Resuscitation Guidelines Bob Bingham RC (UK)

Rationale for the Current Paediatric Resuscitation Guidelines Bob Bingham RC (UK) Evidence? Janssens L, Altman S, Rogers PA. Vet Rec;105(12):273-6. Respiratory and cardiac arrest under general anaesthesia: treatment by acupuncture of the nasal philtrum.

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Rationale for the Current Paediatric Resuscitation Guidelines Bob Bingham RC (UK)

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  1. Rationale for the Current Paediatric Resuscitation Guidelines Bob Bingham RC (UK) Paediatric Anaesthesia Study Day

  2. Evidence?Janssens L, Altman S, Rogers PA.Vet Rec;105(12):273-6. Respiratory and cardiac arrest under general anaesthesia: treatment by acupuncture of the nasal philtrum. “In seven cases of anaesthetic apnoea with concurrent cardiac arrest and absence of vital signs, the revival rate was 43 per cent. Those which recovered required four to 10 minutes of acupuncture stimulation” Paediatric Anaesthesia Study Day

  3. Plan • Evidence evaluation • BLS issues • AEDs • ALS issues • Aspects of airway management • Conclusions Paediatric Anaesthesia Study Day

  4. What we know for sure • Children usually suffer from secondary cardiac arrest • In c.90% of cases bradycardia precedes asystole/PEA • Survival from respiratory arrest is good (c.70% normal at 1 year) • Bystander CPR is associated with improved survival • Rescuers often do nothing for fear of causing harm - because they’re scared that “children are different” Paediatric Anaesthesia Study Day

  5. The Big Idea A universal guideline for all Paediatric Anaesthesia Study Day

  6. “For every complex problem there is an answer that is simple, neat and wrong.” H L Menken Paediatric Anaesthesia Study Day

  7. Effectiveness of ventilation–compression ratios 1:5 and 2:15 in simulated single rescuer paediatric resuscitation E. Dorph, L. Wik and P. A. Steen. Resuscitation 2002;54:259 Paediatric Anaesthesia Study Day

  8. Optimum Compression:Ventilation ratio • More compressions, better CPP • More ventilation better oxygenation • Optimum Balance? Paediatric Anaesthesia Study Day

  9. Optimum Compression:Ventilation ratioBabbs CF, Kern KB. Resuscitation 2002;54:147-57 Paediatric Anaesthesia Study Day

  10. Optimal CPR in ChildrenBabbs CF, Nadkarni V. Resuscitation 2004;61:173 “Compression to ventilation ratios in CPR should be smaller for children than for adults and gradually increase as a function of body weight. Optimal CPR in children requires relatively more ventilation than optimal CPR in adults”. Paediatric Anaesthesia Study Day

  11. So much for the “Big Idea” Paediatric Anaesthesia Study Day

  12. CC+V CC V No CPR ROSC 10 /10 6 /10 6 /10 4 /10 ROSC (<2 min) 10 /10 4 /10 6 /10 0 /10 1-h survival 10 /10 6 /10 6 /10 4 /10 24-h survival 8 /10 5 /10 6 /10 0 /10 24-h neurologically normal 8 /10 4 /10 6 /10 0 /10 Piglet Model of Asphyxial Cardiac ArrestBerg et al 1999. Crit Care Med;27:1893-99 Paediatric Anaesthesia Study Day

  13. Doing anything is better than doing nothing • Ideally children should have a lower compression/ventilation ratio than adults • It’s no use having an ideal if no-one does anything Paediatric Anaesthesia Study Day

  14. Solution • Those “with a duty to respond” will do something. They should employ the optimum, evidence based, sequence • Other responders should be encouraged to do something by making only minimal necessary modifications to the adult protocol Paediatric Anaesthesia Study Day

  15. BLS simplifications • Much of the wording harmonised with the adult text • Age limits: If you think the victim is a child, then he/she is! • Chest compression landmarks – avoiding abdominal compression • AEDs Paediatric Anaesthesia Study Day

  16. AEDs Problem is not giving too large a shock to a child in VF Problem is giving ANY shock to child not in VF Paediatric Anaesthesia Study Day

  17. Fear of Doing Harm • LD50 of shock = 470J/kgBabbs et al. Am Heart J 1980;99:734-738 • LD100 = 0Jkg (if in VF) Paediatric Anaesthesia Study Day

  18. AEDs In Children:Rhythm Analysis Hazinski et al; Circulation 1997Sensitivity 100%; Specificity 100% Atkins et al; Pediatrics 1998Sensitivity 88%; Specificity 100% Ceccin et al; Circulation 2002Sensitivity 100% for VF; Specificity 100% Paediatric Anaesthesia Study Day

  19. Heartstart® FR2 Automated External Defibrillator (50J attenuator) Paediatric Anaesthesia Study Day

  20. Attenuated AEDsAtkins DL, Jorgenson DB. Resuscitation 2005;66:31-37 Pads applied to 27 Patients • 8 were in VF (age: 4.5 months - 10 years) • Shocks were advised and delivered to all • No shock advised to any of the others • All 8 defibrillated and admitted to hospital • 5 discharged Paediatric Anaesthesia Study Day

  21. 50 meters this way, you say? Are we going in the right direction? Paediatric Anaesthesia Study Day

  22. ALS • ALS protocol • VF • Dose of adrenaline • Airway management Paediatric Anaesthesia Study Day

  23. RhythmSamson R, Nadkarni V et al. NEJM 2006;354:2328 Prospective study of 1005 children with in-hospital cardiac arrest: • Non-shockable rhythm 73% • Survival 27% • Shockable rhythm 27% • Survival: • 35% (if VF initial rhythm) • 11% (if VF occurred subsequently) Paediatric Anaesthesia Study Day

  24. Paediatric Anaesthesia Study Day

  25. VF Protocol • Different aetiology - therefore consider precipitating causes • Otherwise, no reason to differ from adult sequence • 4J/kg only Paediatric Anaesthesia Study Day

  26. Dose of Adrenaline? 10mcg/kg? 100mcg/kg? For the 1st dose For the 2nd dose For subsequent doses Paediatric Anaesthesia Study Day

  27. High dose adrenaline • Supported by animal studies and a single retrospective study in children: • No other studies have shown benefit 0/20 survivors after at least two SDE (historical control group) 14/20 survivors with HDE after two failed SDE 8/20 survived to discharge 3/20 neurologically intact at follow-up Goetting. Annals Emerg Med 1991 Paediatric Anaesthesia Study Day

  28. High dose adrenaline • Perondi et al NEJM 2004;250:1722-30 • Blinded PRCT • 68 subjects randomised to HDE or SDE after 1x failed SDE • 24 hr survival HDE: 1/34 SDE: 7/34 • Difference significant, but not maintained following adjustment for differences between the 2 groups • Significantly reduced survival from asphyxial arrest in HDE group Paediatric Anaesthesia Study Day

  29. Airway Management • The “Gold Standard” • LMA • Cuffed tracheal tubes • Other devices Paediatric Anaesthesia Study Day

  30. Effect of out-of-hospital paediatric endotracheal intubation on survival and neurological outcome: a controlled clinical trial.JAMA. 2000 Feb 9;283(6):783-90. Gausche M, Lewis RJ, Stratton SJ, Haynes BE, Gunter CS, Goodrich SM, Poore PD, McCollough MD, Henderson DP, Pratt FD, Seidel JS. • Prospective randomised controlled trial • 830 consecutive patients (<12 years old) • Randomised to BVM or ETI on odd or even dates • Outcomes: survival to hospital discharge and neurological status on discharge Paediatric Anaesthesia Study Day

  31. Outcome by Treatment Received ETI group 420 BVM group: 410 Survival • ETI: 25/185 (14%) • BVM: 208/635 (33%) Good neurological outcome • ETI: 15/185 (8%) • BVM: 162/635 (26%) BUT: results were (correctly) analysed on an ‘intention to treat’ basis Paediatric Anaesthesia Study Day

  32. Gausche et alJAMA. 283(6):783-90, 2000 Outcomes Paediatric Anaesthesia Study Day

  33. Gausche et alJAMA. 283(6):783-90, 2000 Complications Paediatric Anaesthesia Study Day

  34. LMAs?Lopez-Gil M, Brimacombe J et al. (1996) • 8 anaesthesia residents • 75 patients each (600 in all) • The problem rate per patient for overall, major, and minor problems was 31.5%, 12.8%, and 18.7%, respectively • The problem rate decreased from 62% to 2% for overall problems and 23% to 2% for major problems over the 75 patients Paediatric Anaesthesia Study Day

  35. Cuffed Tracheal TubesKhine et al Anesthesiology 1997;86:627-31 488 children (0-8yrs) undergoing general anaesthesia • Initial size tube selected correctly more frequently with cuffed (age/4+3) • Less leak • Same complication rate Paediatric Anaesthesia Study Day

  36. Laryngeal Tube • 0 Newborn <5kg • Infant 5-12Kg • Child 12-25kg • Small adult <155cm • Medium adult 155-180cm • 5 Large adult >180cm Paediatric Anaesthesia Study Day

  37. Laryngeal TubevsLMABortone L et al 2006. Paed Anaesth;16:251-7 Paediatric Anaesthesia Study Day

  38. ETCO2 Monitoring Tracheal tube placement detection reliable with perfusing rhythm and during transport What about during cardiac arrest? (Bhende et al Am J Emerg Med 1996;14:349-50) • Sensitivity 85% • Specificity 100% Paediatric Anaesthesia Study Day

  39. Questions? Paediatric Anaesthesia Study Day

  40. Conclusions Paediatric resuscitation guidelines 2005 • Are evidence based - but it’s not level 1 evidence! They are: • Simpler for professional rescuers • Much simpler for lay rescuers Paediatric Anaesthesia Study Day

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