Selected Pediatric Topics Strive to Survive: Improving Cardiac Resuscitation November 4,2016 Robert W. Hickey, M.D., FAAP, FAHA Professor of Pediatrics Professor of Clinical and Translational Science Children’s Hospital of Pittsburgh of UPMC University of Pittsburgh School of Medicine 1

Disclosures I have no relevant financial relationships to disclose Past Chair of AHA-Peds Committee and AHA-ECC Co-Chair of the 2010 International Guidelines Conference

Learning Objectives Important changes to the Guidelines Impact of layperson CPR upon survival Importance of respirations in pediatric CPR What to do after the arrest

Learning Objectives Important changes to the Guidelines Review of new literature led to upgrading or downgrading for some levels of evidence BUT the guidelines remain mostly unchanged Emphasis remains on good CPR and CPR training

Learning Objectives Impact of layperson CPR upon survival

Evidence Supporting Focus on CPR CPR is important Not enough people get CPR

Focus on CPR CPR is Important Bystander CPR doubles survival of OOH arrest (peds and adults) !!!!!!!! Donoghue et al. Annals Emerg Med 2005;46:512-22

ROSC = Return of Spontaneous Circulation Collapse Bystander CPR ROSC ROSC = Return of Spontaneous Circulation EMS CPR Visible in Studies

Bystander CPR resulting in Collapse Bystander CPR resulting in ROSC = 41 All survived EMS CPR=300 6 survived Sirbaugh et al. Annals Emerg Med 1999;33:174-84

Hickey et al. Annals Emerg Med 1995;25:495-501 Collapse Bystander CPR ROSC Selected pts=11 1 died 3 intubated 3 neuro consults EMS CPR=43 5 survived Hickey et al. Annals Emerg Med 1995;25:495-501

Importance of CPR Bystander CPR MORE THAN doubles survival of OOH arrest (peds and adults)

Not enough people get CPR Focus on CPR Not enough people get CPR Only 1/3 of OOH cardiac arrest victims get CPR prior to EMS arrival (peds and adults) Donoghue et al. Annals Emerg Med 2005;46:512-22

Not enough people who get CPR, get good CPR Focus on CPR Not enough people who get CPR, get good CPR Too few chest compressions Chest compressions are too weak Too many ventilations Too many interruptions

Solutions CC only CPR (CCC)?

Advantages Less complicated to teach and perform Preserve CPP Less fear of infectious disease Less complicated to teach and perform Preserve CPP BUT, will it still work?

Lancet 2007;369:920-926

Kitamura et al Lancet 2010;375:1347-1354

Favorable Neurologic Outcome at 30 Days In 1-17 yo No Bystander CPR CC only CC+V vs CC Only All Pts 34/1632 (2.1%) 20/538 (3.7%) 39/906 (4.3%) Cardiac Cause 14/339 (4.1%) 14/158 (8.9%) 28/282 (9.9%) 1.2 (0.55-2.7) Non-Cardiac Cause 20/1293 (1.5%) 6/380 (1.6%) 45/624 (7.2%) 5.54 (2.5-17)

Arterial Blood Gas (after 7 min of CPR for VF) 7.41±.03 37±5 76±6* * p<0.01 CC 7.49±.02 25±2 92±1* CC+RB pH pCO2 SaO2 …What is the explanation of this finding? The best insight comes from the animal lab ROSC EQUAL Berg, Circulation 1997

Arterial Blood Gas (after 7 min of CPR-asphyxia) SaO2 pCO2 pH CC+RB (15:2) 87±6** 45±8** 7.20±.02* CC 17±5 * p<0.001 97±5 7.01±.06 ROSC BETTER with RB Berg, Circulation 1997

So, why teach CCC CPR?

For every 100 resuscitations in the out-of-hospital setting, 1 For every 100 resuscitations in the out-of-hospital setting, 1.6 will include a child

You could argue that we should teach RB for kids or for respiratory (but this complicates the message and may result in less retention and action)

Who should be taught CPR with ventilations? Anyone likely to resuscitate a child Life guards School teachers Baby sitters To Review

Push Hard, Push Fast

Learning Objectives What to do after the arrest

After the arrest What else Coroner CORE PCP Death Certificate Help with grieving Social workers Personal space Death packet (foot print; lock of hair, etc.) See the back-up of patients What else

After the arrest What else? ---be a detective (doctor) HPI PMH Fam Hx Review previous records (EKGs?)

Post-Mortem Work N Engl J Med. 1999 Oct 7;341(15):1121-5. Followed by case reports in SIDS, aborted SIDS, near drownings…

Case Report 19 yo woman Swimming laps in health club ACLS in field found in 4 ft water ACLS in field QTc = 600 msec Died in ICU 12 h later Ackerman et al NEJM 1999;341:1121-25

Case Report Post-mortem section of myocardium Molecular Diagnosis of the Inherited Long-QT Syndrome in a Woman who Died After Near Drowning Case Report Post-mortem section of myocardium molecular genetic screening for mutations known to cause long-QT syndrome discovered a novel mutation (9-bp deletion) in the KVLQT1 gene Similar case report in a 10 yo near-drowning victim in Pediatrics 1999:101:306-308 Schwartz et al ( NEJM 2000;343:262-267) describe a sodium channel gene mutation in an infant who nearly died of SIDS

Long QT syndrome (LQTS), short QT syndrome, WPW, Brugada syndrome, catecholaminergic polymorphic ventricular tachycardia (CPVT), arrhythmogenic right ventricular cardiomyopathy (ARVC)…

Three Questions How many patients with sudden, unexpected death have a normal autopsy ? How many of these patients will have a channelopathy? Will a diagnosis of a channelopathy in the proband identify other family members at risk for sudden death? The question, as with all case reports is---how common and how important is this?

Three Questions 14-35% (about 1/3rd) How many patients with sudden, unexpected death will have a normal autopsy ? 14-35% (about 1/3rd)

Three Questions How many of these patients will have a channelopathy? 2-10% SIDS 14-20% young adults (2,500/yr) in USA

Three Questions Will a diagnosis of a channelopathy in the proband identify other family members at risk for sudden death? 22-35% of families

YOUR QUESTIONS (screening questions for family history of sudden death) Has anybody in the family died unexpectedly Has anybody died before 50 yo Has anybody drowned Has anybody died in a car accident Is there a family history of seizures or “spells”

A two-year-old boy presents to the ED after a brief LOC A two-year-old boy presents to the ED after a brief LOC. He has lost consciousness four times over a period of five months. Three of the episodes occurred when the child became upset. These episodes had previously been diagnosed as "breath-holding spells”.

Franklin WH, Hickey RW. Long QT syndrome. NEJM 1995; 333:355

Take Home Points Guidelines are mostly unchanged CPR is important Not enough people get CPR (~1/3 of OOH) Bystander CPR doubles survival from OOH arrest Ventilations are important in pediatric CPR Be a detective after the arrest