2015 AHA Guidelines: Pediatric Updates

Transcription

1 2015 AHA Guidelines: Pediatric Updates Advances in Pediatric Emergency Medicine December 9, 2016 Karen O Connell, MD, MEd Associate Professor of Pediatrics and Emergency Medicine Emergency Medicine and Trauma Center Children s National Medical Center

2 Topics of Discussion Epidemiology and outcomes of cardiac arrest 2015 AHA Guidelines for pediatric resuscitation Quality CPR Post-resuscitation management

3 Out-of-hospital cardiac arrest (OHCA): Adults > 300,000 deaths per year in US Leading cause of disability & healthcare costs 60% treated by EMS 20-38% VF or VT as first recorded rhythm 27% receive bystander CPR Significant variability in survival rates for both prehospital and in-hospital

4 Adult Outcomes Prehospital setting: Resuscitation Outcomes Consortium (ROC) Epistry 3%-17% survival range Hospital setting: Get With the Guidelines-Resuscitation QI Program 18% [Range 12%-22%] median hospital survival Hospital arrest characteristics: Peberdy MA, et al. JAMA % during overnight shift vs. >20% during day shift 9% in unmonitored settings vs. 37% in OR/PACU CPR quality: Stiell IG, et al. Crit Care Med 2012; Abella BS et al, Circ 2005 CP depth <38mm (1.5in), survival reduced by 30% CP rate too slow, survival reduced from 72% to 42%

5 Out-of-hospital cardiac arrest (OHCA): Pediatric 16,000 pediatric cardiac arrests per year in US OHCA: Donoghe AJ et al. Ann Emerg Med 2005; Young et al. Pediatr 2004; Sutton RM, et al. Resus 2015 Survival by age: 3-4%, Infants <1yr 9-11%, Children 1yr to 11 yrs 9-16%, Adolescents Hospital Setting: Knudson JD et al. Crit Care Med 2012; Gupta P, et al. Resusc 2014; Get With the Guidelines-Resuscitation QI Program 78% acute resuscitation survival 22-36% median hospital survival Neurologic morbidity remains high in survivors

6 Out-of-hospital cardiac arrest (OHCA): Pediatric Factors associated with favorable outcomes Witnessed arrest (13.1% vs. 4.6%) Drowning etiology Bystander CPR (9.4% vs. 4.7%) Short duration of CPR >20 minutes indicator of mortality (OR 10.35, 95%CI 4.59 to 23.32) ] Fewer doses of epinephrine VF rhythm (30%) compared to systole or PEA (0-5%) **No difference in survival for ALS vs BLS care Donoghe AJ, Nadkarni V, Berg RA, et al. Ann Emerg Med 2005; Lopez J et al. Resuscitation 2004; Pitetti R, et al. Prehospital Emerg Care 2002

7 Pediatric OHCA Etiology Most common = tissue hypoxia and acidosis from respiratory failure and/or shock Initial rhythms: overall Asystole 78% VF/pulseless VT 18% PEA 13% Submersion: Asystole 61.4% VF/pulseless VT 20% Bradycardia 15.7% Unknown 2%

8 Pediatric OHCA Challenges Pediatric cardiac arrest = low frequency event Little experience at the level of the individual provider AHA GWTG-R database: Median incidence of zero events 95 th percentile of 4 per year Challenge with skill and knowledge maintenance Decline in CPR knowledge/psychomotor skill in as little as 3 months Current training schedule recommendations are every 1-2 years

9 Chain of Survival Infants and Children Witnessed cardiac arrest Early defibrillation/aed use Unwitnessed cardiac arrest Perform CPR for 2 minutes before AED

10 2015 Chain of Survival Infants and Children

11 Resuscitation

12 Quality CPR To maximize survival---focus on Quality of CPR Poor-quality CPR is considered a preventable harm CPR is inherently inefficient 10%-30% of normal blood flow to heart 30-40% of normal blood flow to brain GOAL = Cardiocerebral Resuscitation High performance CPR improves defibrillation shock and medication effectiveness

13 CPR Performance: Pediatric studies Chest compression rate: <100 5% % >120 67% >150 26% Ventilation rate: % % >30 39% C:V Ratio in non-intubated pts 15:2 4% Duration of compressions by individual provider <120 sec 77% >120 sec 23% No-flow fraction (% of time NO CPR) <20% - Median 9%, range 0-12%

14 High Quality CPR 1. Minimize chest compression interruptions: <10 secs Chest compression fraction goal >80% 2. Provide chest compressions at a rate of /min 3. Provide chest compressions at an adequate depth Adult: 2 inches (5cm) Children (age 1 yr-puberty): 1/3 AP diameter of chest (~2 in or 5 cm) Infant (age <1yr, excluding newborns): 1/3 AP diameter of chest (~1 ½ inches or 4cm) 4. Avoid leaning between compressions 5. Avoid excessive ventilation: Rate <12/min, minimal chest rise

15 Team work is KEY Have defined roles Drill repeatedly Know role specific expectations Adequate workspace Pit Crew CPR Identify physical and mental workspace Rapid assessment Start CPR early High performance CPR Drill the skills

16 Pit Crew CPR

17 Chest compressions Synchronous:(BVM) Adult: 30 CC: 2 breaths Children/Infants: Single provider 30 CC: 2 breaths Children/Infants: >2 providers 15 CC: 2 breaths Asynchronous:(advanced airway) Adult and children/infants: Continuous chest compressions Rate /min 1 breath every 6 seconds 10 per minute *Chest compression-only CPR is not recommended for children

18 Infants 1 Rescuer Chest compression technique 2 fingers, center of sternum just below nipple line Easier transition from CP to ventilation 2 or more rescuers 2 thumb-encircling hands, center of sternum just below nipple line Associated with better depth, rate, and consistency Children 1 or 2 hands over lower half of sternum 1 hand: slower rate of compressions 2 hand: increased rescuer fatigue

19 Monitoring CPR Performance Human supervision and CPR direction Monitor feedback Audiovisual feedback devices during CPR Capnography ETCO2>20 mmhg=goal ETCO2 dependent on pulmonary blood flow reflects cardiac output ETCO2<10mmHg reflects poor cardiac output and predicts unsuccessful resuscitation Abrupt sustained increase to normal (35 to 40 mmhg) is indicator of ROSC :

20 AED/Defibrillation Success of conversion of VF dependent upon: Time delay before delivering shock Defibrillation efficiency Thoracic impedance Energy dose Waveform Optimal dose/ upper limit for safe defibrillation not known Wide margin between therapeutic and toxic doses Animal studies: (monophasic shock) Dose necessary to convert 50% = 1.5 J/kg Dose causing myocardial damage in 50% = 30 J/kg Lethal dose for 50% = 470 J/kg Babbs CF et al. Am Heart J 1980 :

21 AED/Defibrillation AED recommendations, 2015 Pediatric dose attenuating system should be used for infants and children <8yrs whenever possible Dose = 50J with pediatric pads When pediatric attenuators are not available, adult AED is recommended Defibrillation (biphasic) Dose= 2 J/kg, then 4J/kg to max of 10J/kg :

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23 Post Resuscitation Stabilization Vasoactive medications to maintain cardiac output Preserve brain function; prevent secondary neuronal injury Maintain normoventilation Aggressively treat fever and seizures Hypothermia protocols for adults Therapeutic hypothermia (32-34 C) for children THAPCA OHCA study multi-center study of pediatric OHCA No difference in functional outcomes at 1 year No additional complications in the hypothermic group THAPCA Inpatient study results pending

24 Critical Care: Invasive monitoring GOALS = Post Resuscitation Stabilization Maximize Cerebral Blow Flow (CPP=MAP-ICP) MAP mmhg ICP 10 mmhg CPP mmhg Coronary Perfusion Pressure (CPP)>20 mmhg Diastolic blood pressure >25-30 mmhg

25 Improving Outcomes Training and skills maintenance Most effective training is simple, realistic, scenario driven and hands on Continuous quality improvement Systematic evaluation and feedback Measurement and benchmarking If you don t measure it, you can t improve it Analysis report cards Debriefing after events

26 THANK YOU Questions and Comments?