ILCOR, ARC & NZRC PAEDIATRIC RESUSCITATION RECOMMENDATIONS 2010

Transcription

1 ILCOR, ARC & NZRC PAEDIATRIC RESUSCITATION RECOMMENDATIONS 2010 Jim Tibballs Officer, RCH Convenor, Paediatric Sub-Committee, (ARC) ARC Paediatric Representative International Liaison Committee on (ILCOR)

2 CONFLICT of INTEREST No financial Intellectual Member of ARC ILCOR delegate Co-author of some studies

3 Present some 2010 ILCOR recommendations Present rationale of a few changes Identify departures by ARC & NZRC (&ERC) from ILCOR recommendations Identify some ARC & NZRC recommendations not considered by ILCOR

4 2010 ILCOR 55 clinical subjects 20 new recommendations 7 need to know recommendations Medical emergency team Starting CPR Pulse palpation Breaths vs no breaths Compression:ventilation ratios Infants and children Newborns outside delivery room Exhaled CO2 monitoring DC shock dose Oxygen Hypothermia

5 ILCOR GUIDELINES published Oct-Nov 2010 <www,ilcor.org> 2010; 81: e213-e259 (Oct) Circulation 2010; 122: S466-S515 (Oct) Pediatrics 2010: 126(5):e (Nov) paediatric guidelines summary of changes to guidelines JT 2011

6 Medical Emergency/Rapid Response Team/Early Warning Scores ILCOR Pediatric RRT or MET systems may be beneficial to reduce the risk of respiratory and/or cardiac arrest in hospitalized pediatric patients ARC and NZRC All institutions should have a system which enables staff at the bedside to quickly summon expert help to assist in the management of serious-illness. Examples of such systems are medical emergency team (MET) or rapid response team (RRT) systems

7 Chan PS, Jain, R. et. al.(2010) Rapid Response Teams: a systematic review and meta-analysis. Arch Intern Med. 170(1):18-26 Results: Rate of Cardiopulmonary Arrest ( 38%) Control Post Intervention Wt. RR (95% CI ) # pts Dths # Pts Dths

8 Chan PS, Jain, R. et. al.(2010) Rapid Response Teams: a systematic review and meta-analysis. Arch Intern Med. 170(1):18-26 Results: Hospital Mortality Rate ( 21%) Control Post Intervention Wt. RR (95% CI ) # pts Dths # Pts Dths

9 STARTING CPR If the victim is unresponsive and not breathing normally (ILCOR and there are no signs of life) and if cannot palpate a pulse within 10 seconds with certainty, start CPR

10 PULSE PALPATION ( 2009; 80: ; 81: 671) Accuracy 78% - all doctors and nurses Sensitivity 86% (diagnose CA correctly BUT fail to diagnose CA 14%) Specificity 64% (exclude CA correctly BUT diagnose CA incorrectly 36%) Average 15 seconds to exclude CA when truly absent Average 30 seconds to confirm CA when truly present Experienced doctors correctly diagnose CA within 10 seconds

11 INITIAL BREATHS ILCOR 2010 Silent ILCOR 2-5 (2005) AHA start ECC first ARC & NZRC Start ECC first 2 breaths first optional ERC 5 breaths first JT 2011

12 Advanced Life Support for Infants and Children Can give 2 breaths first Shockable Start CPR 15 compressions : 2 breaths Minimise Interruptions Attach Defibrillator / Monitor Assess Rhythm Non Shockable During CPR Airway adjuncts (LMA / ETT) Oxygen Waveform capnography IV / IO access Plan actions before interrupting compressions (e.g. charge manual defibrillator to 4 J/kg) Drugs Shockable * Adrenaline 10 mcg/kg after 2 nd shock (then every 2 nd loop) * Amiodarone 5mg/kg after 3 rd shock Non Shockable * Adrenaline 10 mcg/kg immediately (then every 2 nd loop) Shock (4 J/kg) CPR for 2 minutes Return of Spontaneous Circulation? Adrenaline 10 mcg/kg (immediately then every 2 nd cycle) CPR for 2 minutes Consider and Correct Hypoxia Hypovolaemia Hyper / hypokalaemia / metabolic disorders Hypothermia / hyperthermia Tension pneumothorax Tamponade Toxins Thrombosis (pulmonary / coronary) Post Care JT 2011 Post Care Re-evaluate ABCDE 12 lead ECG Treat precipitating causes Re-evaluate oxygenation and ventilation Temperature control (cool) December 2010

13 COMPRESSION : VENTILATION RATIO 15:2 Why not 30:2 ratio for infants and children? JT 2011

14 Why not 30:2 for paediatrics? No human evidence Consensus with adult scientists NOT achieved. (Paediatricians not persuaded by animal cardiac arrest studies, mannekin studies and computer simulations) Rationale conjecture: Paediatric ventilation requirement greater than adult Hypoxic arrest, not sudden arrhythmia arrest, more common in paediatric practice In out-of-hospital paediatric cardiac arrest (Kitamura et al., Lancet 2010; 375: 1347) Survival from asphyxial cause better (7.2%) with standard CPR (7.2%) vs compression-only CPR (1.6%) vs no CPR (1.5%) Survival from cardiac cause same with standard CPR (9.9%) vs compression-only CPR (8.9%) vs no CPR (4.1%) 15:2 previously used for children (one-person rescue) JT 2011

15 Compression-ventilation ratios for infants JT 2011

16 Compression : ventilation ratio for infants (Term infants out of delivery area within first month) At birth 3:1 ILCOR In non-neonatal setting (eg ED, PICU, prehospital) or with cardiac aetiology regardless of location: No ETT prefer 15:2 over 3:1 ETT continuous compressions no pauses for ventilations (15:2) For use of training use what is commonly used in your environment ARC & NZRC In ED, PICU, wards, prehospital setting use 15:2 With exception of newborns, with cardiac aetiology regardless of location: No ETT - 15:2 ETT - continuous compressions no pauses for ventilation 10/min

17 Ventilations after intubation ILCOR reduce 2010 AHA 8-10/min (no circ) 12-20/min (circ) ARC & NZRC 10/min ERC 10-12/min JT 2011

18 Compression : Ventilation ratio after intubation 10:1 JT 2011

19 Compression Ventilation Cycles Basic CPR 30:2 (single rescuer) 2010 ILCOR silent AHA 5 in 2 min* ARC & NZRC 5 in 2 min* ERC silent 75 compressions/minute 5 breaths/minute JT 2011

20 Compression Ventilation Cycles Advanced CPR 15:2 (2 rescuers) 2010 ILCOR silent AHA 5 in 1 min* ARC & NZRC 5 in 1 min* ERC silent 75 compressions/minute 10 breaths/minute JT 2011

21 DC shock dose JT 2011

22 Dose of DC Shock (Single shock strategy) ILCOR CoSTR 2-4 J/kg AHA 2-4 J/kg ARC & NZRC 4 J/kg ERC 4 J/kg JT 2011

23 Joules Biphasic DC shock for VF and pulseless VT Pediatr Crit Care Med 2011; 12: J/kg 4J/kg 3J/kg J/kg J/kg ROSC non-rosc ROSC 50% if 2J/kg ROSC if 3-5 J/kg Body weight (kg) N=48 JT 2011

24 Copyright 2011 American Academy of Pediatrics Outcomes according to shock dose Meaney, P. A. et al. Pediatrics 2011;127:e16-e23

25 Monitoring exhaled CO 2 JT 2011

26 1. To detect non-tracheal intubation (standard of care) 2. Assess effectiveness of CPR JT 2011

27 Monitoring end-tidal CO2 (PetCO 2 ) ILCOR May guide effectiveness of chest compressions. If PetCO 2 is < 15 mmhg, improve chest compression and reduce ventilation ARC & NZRC Low PetCO 2 may be due to excessive positive pressure ventilation or inadequate chest compressions or both Cannot yet identify threshold to stop CPR

28 Quantifying the effectiveness of CCs End tidal C02 will rise as pulmonary blood flow and overall cardiac output rises, assuming that the amount of ventilation (tidal volume and rate) does not change Jin, CCM, 2000

29 Assessing effectiveness of CPR No ROSC low end-tidal CO 2 ROSC normal end-tidal CO 2 Krep H, Mamier M, Breil M, et al ;73(1):86. JT 2011

30 Partial pressure of end-tidal carbon dioxide successfully predicts cardiopulmonary resuscitation in the field: a prospective observational study. Kolar et al., Crit Care 2008;!2: R intubated cases out-of-hospital cardiac arrest After 20 minutes of CPR: 402 cases of ROSC when PetCO 2 mean 33+/-9 mmhg 335 cases of non-rosc when PetCO 2 mean 7+/-2 mmhg PetCO 2 <14 mmhg reliably predicts (100%) non-rosc PetCO 2 >14 mmhg reliably predicts (100%) ROSC

31 Oxygen ILCOR Cannot specify oxygen concentration during resuscitation After resuscitation, titrate oxygen concentration to limit hyperoxemia ARC & NZRC Use 100% oxygen initially for resuscitation After resuscitation reduce to yield PaO mmhg

32 Hypothermia ILCOR Hypothermia (32-34 degrees) may be considered for those remaining comatose after resuscitation ARC & NZRC It is acceptable to induce hypothermia (32-34 degrees) within 6 hours and maintain up to 72 hours in those remaining comatose after resuscitation

33 Principles of Guideline Formulation Survival = Science x Education x Implementation JT 2011

34 ... the debate will continue, especially when data is lacking, after all It s not necessary to understand things in order to argue about them Il n est pas nécessaire de tenir les choses pour en raisonner (Pierre Beaumarchais. Le Barbier de Séville)