Pediatric Resuscitation: New Guidelines Update 2002 Arno Zaritsky, M.D. ©2000 American Heart Association 1

PBLS & PALS Guidelines New guidelines published in August 22, 2000 addition of Circulation NRP guidelines on Pediatrics web site: www.pediatrics.org/cgi/content/full/106/3/e29 (September 2000) Changes in new guidelines summarized in Currents: www.americanheart.org/cpr (Currents Newsletter) PALS Instructors Manual December 2001 and Textbook published March 2002

Levels of Evidence Level 1 Large RCTs in humans Level 2 Small RCTs in humans Level 3 Prospective, non-randomized Level 4 Historic controls, non-randomized Level 5 Human case series Level 6 Animal studies Level 7 Rational extrapolation Level 8 Rational conjecture (common sense)

Class of Recommendations Class I: Proven safe and effective Excellent evidence; LOE 1 Class IIa: Acceptable, useful Good-to-very good evidence; LOE 2-4 Class IIb: Acceptable, useful Fair-to-weak evidence; LOE 4-8 Class III: Unacceptable, harmful Class Indeterminate: Inadequate data

PBLS: 1992-2000 Only 30% of kids receive bystander CPR CPR: a complex psychomotor task Difficult to teach, learn, remember, and perform Often poorly performed Pulse check

“For crying out loud, I was HIBERNATING! …Don’t you guys ever take a pulse?

Pediatric Basic Life Support Pulse check: time-consuming and unreliable Lay rescuer: no pulse check (IIa) Healthcare provider: check for “signs of circulation” (breathing, movement, response) and pulse ~10 secs

PULSE CHECK Accuracy in Identifying Cardiac Arrest Rescuers take too long to decide if pulse present (median time: 24 sec; only 15% decided within 10 sec) Sensitivity 90% to identify absent pulse (10% of victims in pulseless arrest would be “missed”) Specificity 60% (40% of victims with pulse would receive compressions) Overall error rate 35%

Compression-Ventilation Ratio Consensus among resuscitation councils was to maintain age-specific rates: Newly born 3:1 Children < 8 5:1 Children > 8 15:2 Note: do not need to maintain ratio once patient is intubated

Compression-Ventilation Ratio Rationale for recommendation: Respiratory problems are the most common cause of pediatric arrest Physiologic respiratory rates in infants and children are faster than in adults Adult compression rate important to maintain coronary perfusion pressure Current providers are trained and accustomed to these ratios

Ventilation during CPR The rescuer should use only the force and tidal volume necessary to cause the chest to rise visibly. Larger tidal volumes recommended if ventilating with room air

Complications of Over-ventilation Compromises cardiac output – positive pressure ventilation, auto-PEEP Raises intrathoracic pressure Risk of barotrauma Distends stomach Impedes ventilation Increases risk of aspiration Hyperventilation in head injured patient may be harmful

Goals of BVM Ventilation Approximate normal ventilation and achieve physiological oxygen and carbon dioxide levels while minimizing risk of iatrogenic injury. [Class IIa] Hyperventilate if signs of increased ICP

Chest Compressions 2-thumb, encircling hands preferred to 2-finger compression technique (Class IIb, LOE 5) Achieves higher peak systolic and coronary perfusion pressure providers prefer this technique

“Thank heavens the plumber knows CPR!”

Pediatric Airway and Breathing Best prehospital approach depends on training, skills, and situation Endotracheal intubation (ETI): not Gold Standard in all circumstances BVM: needs emphasis in training may be preferable to ETI in prehospital setting with short transport time (IIa)

Pediatric ETI vs BVM in Prehospital Setting (Gausche JAMA 2000; 283:783) No difference in overall survival BVM: 123/404 (30%) ETI: 110/416 (26%) Odds ratio, 0.82 (95% CI, 0.61-1.11) BVM better survival for respiratory arrest BVM: 46/54 (85% survival) ETI: 33/45 (61% survival) OR, 0.27 (95% CI, 0.11-0.69)

Prehospital ETI problems 57% successful intubation rate Longer time at scene (2-3 minutes) 2% esophageal intubation rate 6% unrecognized extubation rate 14/15 with esophageal intubation or unrecognized extubation DIED Gausche JAMA 2000; 283:783

Align the oral (O), pharyngeal (P) and tracheal (T) planes: Elevate the occiput and extend the head. Looking from side, note the ear anterior to the shoulder—”sniffing rose” position.

Cricoid pressure reduces risk of aspiration Only use in unconscious patient Don’t distort trachea

Confirmation of ET Tube Placement PALS emphasizes advanced airway management to prevent arrest But, we should avoid morbidity/ mortality from this intervention Who should perform prehospital ETI? Is exhaled CO2 detection reliable in children and can its use increase safety of ETI?

Intubation Case A 4-year old child with CP and a seizure disorder is found unresponsive at home and 911 is called CPR is begun by family; EMS arrives and intubates child with a 5 mm ET tube Breath sounds are heard bilaterally, but no air heard over stomach Exhaled CO2 detector shows no color change What would you do now? What does this mean?

Intubation Case Confirm placement of tracheal tube by direct visualization Assure that proper closed chest compression is being performed

Exhaled CO2 Detection pH sensitive filter paper Detects exhaled CO2 >0.5% (~4 torr) Specific for correct tube placement when color changes Increases airway resistance

Exhaled CO2 = 10 torr PaCO2 = 25 torr PvCO2 = 100 torr

Expired CO2 False negative: inadequate pulmonary blood flow or severe airway obstruction Expired CO2 correlates with effectiveness of compression-induced cardiac output Absent color change correlates with death in cardiac arrest Transient decline in pulmonary blood flow following epinephrine Massive pulmonary embolus Pulmonary edema (ARDS)

Expired CO2 False positive: Contamination of device with secretions or drugs may cause fixed color change Spontaneously breathing patient with tube in the posterior pharynx rather than trachea

Exhaled CO2 (yellow) Normal (purple)

Conclusions: Confirmation of Tube Position No single confirmation device or exam technique is 100% reliable under all circumstances Expired CO2 detection is reliable in perfusing patient Expired CO2 is specific, but not sensitive for tracheal position in cardiac arrest patient Repeat confirmation after patient movement

Intraosseous access Expand to > 6 yo (Class IIa) OK in neonates, if umbilical vessels not accessible (Class IIb) Encourage IO without delay for cardiac arrest and decompensated shock

Drug and Equipment Selection Broselow® tape based on 50% weight for length Broselow tape used to estimate weight, calculate drugs and select ETT and other equipment

Broselow Resuscitation Tape

VF in kids VF is uncommon, but not rare 5-20% prehospital arrests (excluding SIDS) Appropriate Rx is DEFIBRILLATION New recommendations: Emphasis on early cardiac rhythm analysis Physicians responsible to notify at-risk families to learn CPR and “phone 1st” AEDs may be used if > 8 yo (Indeterminate)

Drug therapy in cardiac arrest Epinephrine is the drug of choice Initial dose of 0.01 mg/kg Data do not support subsequent high doses of epinephrine; may be considered (IIb), but not recommended. Consider in sepsis, beta-blocker overdose, etc. Vasopressin: potent selective vasoconstrictor for skin, muscle, intestine and fat with relatively little effect on vessels in heart & brain Clinical and animal studies are supportive Asphyxial model: no benefit Not recommended (Indeterminate)

Drug Therapy: Magnesium Torsades de pointes ventricular tachycardia Often related to drug toxicity Acute asthma unresponsive to ß-adrenergic agonists 25 - 50 mg/kg slow IV infusion over 10-20 minutes; max. dose 2 g Monitor BP and HR Side effect: hypotension and bradycardia

Anti-arrhythmic therapy Refractory ventricular tachycardia or fibrillation 3 shocks, IV/IO epinephrine, 4th shock Amiodarone (Indeterminate) Lidocaine (Indeterminate) High-dose epinephrine (Class IIb) Vasopressin (Indeterminate) Bretylium (Class III) – not recommended, high-risk of hypotension

Amiodarone Complex pharmacology: highly lipid soluble; non-competitive inhibitor of SNS VERY long half-life Blocks outward K+ current  prolonged QT Inhibits Na+ channels  slows conduction and prolongs QRS duration. Use-dependent inhibition  works best at high rates Useful in SVT, VT, JET, EAT and VF Limited peds data, but based on adult data, considered drug of choice in shock-resistant VF/pulseless VT over lidocaine

Amiodarone FDA warning issued March 21, 2001 Plasticizer may be leached out during slow infusions – concerns about effects on male reproductive tract “Gasping syndrome” – benzyl alcohol Neonatal toxicity – gasping respirations, hypotension, bradycardia and cardiovascular collapse

Case A 15-year old is brought to the ED by EMS after being found unresponsive in the bathroom She had a fight with her boyfriend earlier in the day She is noted to have occasional PVCs on the monitor with widened QRS complexes Shortly after arrival she begins to seize What do you want to do?

Toxicology (examples) Tricyclic antidepressants: Sodium bicarbonate (IIb) Calcium-channel blocker overdose: IV calcium (IIb) Narcotics: Naloxone (IIa) Ventilation prior to naloxone (IIb)

Post-resuscitation care Avoid routine hyperventilation (Class III) Avoid rewarming unless core temp <33o C (Class IIb) Treat hyperthermia with active cooling (Class IIa) Post-resuscitation myocardial dysfunction is common: Rx it!!

Avoiding Hyperthermia Worsens injury after hypoxic-ischemic insult (animals) Extension of infarct size and worsening of outcome after ischemic stroke (adults) Association of cerebral palsy with maternal infection/fever (neonates)

Initial Steps Provide warmth avoiding hyperthermia Position, clear airway (as necessary) tracheal suctioning for meconium Dry, stimulate, reposition Give O2 (as necessary)

Neonatal Resuscitation Room air vs. 100% Oxygen If assisted ventilation is required, 100% oxygen should be delivered by positive pressure ventilation … If supplemental oxygen is not available, resuscitation of the newly born infant should be initiated with positive pressure ventilation and room air. [Indeterminate Class, level 2 evidence]

Meconium Aspiration (n=1051) (n=1043) 12 centers Intubate Expectant (n=1051) (n=1043) Overall (n=149) 74 (7.0%) 75 (7.2%) MAS (n=62) 34 (3.2%) 28 (2.7%) Other (N=87) 40 (3.8%) 47 (4.5%) Wiswell Pediatrics 2000

Neonatal Resuscitation Meconium Direct endotracheal suctioning is not necessary in vigorous infants with meconium-stained fluid. [Class I, level 1 evidence] Direct endotracheal suctioning, using the endotracheal tube as a suction catheter, should be performed if the neonate is depressed (weak or absent respirations, poor tone, HR < 100 bpm). Delay gastric aspiration until initial resuscitation is complete. Best to suction airway on the perineum

Neonatal Resuscitation Volume expansion Albumin and other colloids may increase mortality in critically ill patients. Also, more expensive. Therefore, volume expansion may be accomplished with (1) isotonic crystalloid such as normal saline or Ringer’s lactate or (2) O-negative blood. [Class IIb, level 7 evidence]

Neonatal Resuscitation: Chest compressions Begin if HR < 60 bpm despite adequate ventilation for 30 seconds 120 events per minute: 90 compressions:30 ventilations Two-thumb encircling technique is preferred Compress ~1/3 of AP diameter of chest

Neonatal Resuscitation: Post-resuscitation Avoid and correct hyperthermia Experimental data suggest benefit from induction of cerebral hypothermia but insufficient data (Class Indeterminate)

Avoiding Hyperthermia Potentiation of injury after perinatal hypoxic-ischemic insult (animals) Extension of infarct size and worsening of outcome after ischemic stroke (adults) Association of cerebral palsy with maternal infection/fever (neonates)

Questions??

Neonatal Resuscitation Ethics Non-initiation of resuscitation in the delivery room in infants with confirmed gestation < 23 weeks, birthweight < 400 grams, or with anencephaly or confirmed trisomy 13 or 18 may be appropriate. Current data support that resuscitation of these newborns is very unlikely to result in survival or survival without severe disability. [Class IIb, level 5 evidence]

Neonatal Resuscitation Ethics In cases of uncertain prognosis, including uncertain gestational age, a trial of therapy, non-initiation, or discontinuation of resuscitation remain options following assessment of the baby. Ongoing evaluation and discussion with the parents and the health care team should guide continuation vs. withdrawal of support.

Neonatal Resuscitation Ethics Discontinuation may be appropriate after 15 minutes of absent heart rate despite complete and adequate resuscitation efforts. Current data support that resuscitation of newborns after 10 minutes of asystole is very unlikely to result in survival or survival without severe disability.

Avoiding Hyperthermia Hyperthermia should be avoided… because it is associated with perinatal respiratory depression (Class III, LOE 3). Maternal fever and neonatal respiratory depression Lieberman E, et al. Pediatrics 2000; 105:8 Perlman JM. Clin Pediatr 1999; 38:287

PALS: Airway & Ventilation Bag—mask ventilation: increased emphasis Selective endotracheal intubation Confirmation of tracheal tube position