Paediatric Resuscitation. EMS Rounds Gurinder Sangha MD Paediatric Emergency Fellow June 18, 2009

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1 Paediatric Resuscitation EMS Rounds Gurinder Sangha MD Paediatric Emergency Fellow June 18, 2009

2 Essentials of Resuscitation Airway Breathing Circulation

3 AIRWAY

4 Differences in Paediatric Airway Shorter and smaller diameter More anterior larynx Larger tongue and head Long, floppy, narrow epiglottis Narrowest portion of airway is subglottic Relatively more pink vocal cords

5 Paediatric vs Adult Airway

6 Special Considerations Syndromes (eg. Trisomy 21) Congenital Abnormalities (eg. Micrognathia) Cerebral Palsy (secretions, decreased tone)

7 Airway Interventions Head tilt and chin lift Jaw thrust Beware hyperextension

8 Airway Positioning

9 Airway Adjuncts oral airway No gag/cough present Correct sizing

$Basal skull fracture Coagulopathy (nasal mucosal$

10 Airway adjuncts NP airway Contraindications: Basal skull fracture Coagulopathy (nasal mucosal tears)

11 Indications to Intubate Inadequate oxygenation Inadequate ventilation Airway protection Anticipatory (long transport, hematoma)

12 Intubation - Equipment Curved Blade Straight Blade

13 Intubation Straight Blade Used to pick up the epiglottis Better for infants/toddlers with a floppy epiglottis

14 Intubation Curved Laryngoscope Placed in the vallecula Better for older children with a more stiff epiglottis

15 Intubation Curved vs Straight Choose for comfort

16 Intubation Tube Size Age/4 + 4 Diameter of pinky finger Broselow tape Always have 1 size larger and smaller than anticipated

17 Intubation Tube Placement ETT depth use the black line Approximated by (Age/2) + 12

18 Intubation Tube Selection Cuffed versus Uncuffed Uncuffed up to age 8 years

19 Intubation Remember it is ventilation and oxygenation that is most important, not intubation!!

20 Intubation - EMS Gausche et al, JAMA 2000 RCT comparing BVM versus endotracheal intubation by EMS in Los Angeles 830 patients total, under 12 years of age 57% successfully intubated No difference between BVM and ETI in survival or neurologic outcome

21 Breathing

22 Paediatric Cardiopulmonary Arrest 10% 10% Primary Respiratory Shock Primary Cardiac 80%

23 Breathing Adequate oxygenation and ventilation are key!!!

24 Breathing - Ventilation Look listen feel Best indicator of adequate ventilation is chest rise BVM -1 breath every 3 seconds (20/minute) for infants and children

25 Breathing - Oxygenation Apply O2 as soon as possible Use 100% No adverse effects in the short term

26 Circulation

27 Circulation Normal heart rates Neonate Infant Child

28 Circulation Blood Pressure Minimal systolic blood pressure = 70 + (2x age)

29 Circulation Pulse check Neonate: umbilical stump or apical Infant: brachial or femoral Child: carotid

30 Circulation - Compressions Neonate Indication: HR <60 after BVM x 30sec Location: lower 1/3 of sternum Depth: 1/3 depth of chest Method: thumbs with chest encircled Rate: 120/min Ratio: 3:1

31 Circulation - Compressions Infant Indication: HR <60 & poor perfusion or no pulse Location: just below nipple line Depth: 1/3 1/2 depth of chest Method: Index + middle finger or as neonate Rate: 100 /min Ratio: 15:2

32 Circulation - Compressions Child Indication: HR <60 & poor perfusion or no pulse Location: at nipple line Depth: 1/3 1/2 depth of chest Method: one or 2 handed method Rate: 100 /min Ratio: 15:2

33 Circulation Cardiac Arrest Vast majority of cardiac arrests are secondary to respiratory arrest in children Primary cardiac arrest: Congenital heart disease Hereditary disorders of rhythm Electrolyte disturbances Ingestion

34 Paediatric Cardiac Arrest (Atkins et al, Circulation 2009) More common in infants than children and adolescents Overall survival for all paediatric OHCA that receive EMS treatment was 7.8% Survival rates for OHCA in children and adolescents double that of adults or infants Number needed to treat = 13

35 Paediatric Cardiac Arrest (Atkins et al, Circulation 2009) Vast majority of paediatric primary cardiac arrests are asystole/pea VF/VT seen in 7% out of hospital arrest (previously reported rates 5-19%) VF/VT survival 20% versus 5% in asystole/ PEA

36 VF/VT in Paediatrics ACP s 1 st defibrillation at 2 J/kg Subsequent defibrillations at 4 J/kg Epinephrine 1:10,000 (0.1cc/kg) IV or 1:1000 (0.1cc/kg) ETT q 3-5min (max 3 doses prior to patch) Lidocaine 1 mg/kg IV/IO or 2 mg/kg ETT (max 2 doses)

37 VF/VT in Paediatrics PCPs Patients greater than 1 year (treat as those greater than 8 years) Apply AED with paediatric attenuator cables if available, otherwise apply with normal adult cables and provide shock as per analysis with adult energies (120, 150, 200 J) Is this safe???

38 Defibrillation in Paediatrics Dosages of 2 J/kg and 4 J/kg shown to be minimum effective dose in 27 patients (Gutgessal et al, Paediatrics 1976) Multiple animal studies show conflicting evidence regarding the detrimental effects on paediatric hearts using adult dosages

39 Defibrillation in Paediatrics (Rossano et al, Resuscitation 2006) Reported on 57 patients with OHCA requiring defibrillation No difference in survival between patients receiving recommended dosage (2J/kg, then 4J/kg), moderately high dose (2-4J/kg, followed by >4J/kg), and high dose (>4J/kg) Given the known benefits of early defibrillation (especially in adults), shock with adult cables if no paediatric cables available

40 Defibrillation in Paediatrics No controlled studies comparing adult to paediatric dosages Studies advocating paediatric attenuator cables small and observational

41 Cardiac Arrest Paediatrics When to transport? One no shock indicated (PCP s) OR One non VF/VT rhythm analysis (ACP s) 4 shocks OR *Do not stay on scene with a paediatric* patient in a non-shockable rhythm, load and go

42 Cardiac Arrest Vascular Access 2 attempts at peripheral IV (or 90 seconds) If unsuccessful then attempt IO Anterior tibia 1-3 cm below tuberosity, and medial

43 Intraosseous Insertion

44 Intraosseous Placement

45 Intraosseous Considerations Do not place if fracture suspected Should be able to get blood back, if not, attempt to infuse ensuring no extravasation at site

Pediatric Cardiac Arrest General

Date: November 15, 2012 Page 1 of 5 Pediatric Cardiac Arrest General This protocol should be followed for all pediatric cardiac arrests. If an arrest is of a known traumatic origin refer to the Dead on